134. The Rare and Imported Pathogens Lab (RIPL)

Now this an episode, first of a triple 

About all the work of a lab called RIPL 

And we'd like to take minute now so sit right here 

And learn about all the horrible pathogens you now should fear

Transcript

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Callum 0:23

hello, amy. Hello, Claire. Welcome to the Idiots Podcast. Thank you so much for joining us. Jay and I are honored to be joined by Dr. Claire Gordon, who's head of the imported Pathogen Laboratory Clinical Services, and by Dr. Amy Bellfield, is a rare imported pathogen lab clinical fellow.

claire ripl 0:51

Thought your about say she is a rare imported pathogen. It's like, yeah, I'll do own it.

Callum 0:57

That's something we can all aspire to. I'm not sure any of us can claim yet. If you look at the art for the podcast, I think Jane and I are not rare imported pathogens. We're just bog standard, boring bacteria. But I guess sometimes the diagnosis, isn't it? Thank you so much for coming on the show. And I guess I thought I would start with a very serious question. What's your favorite chocolate bar?

claire ripl 1:24

I know I'm supposed to say Ripple.

Callum 1:28

Is it, I don't know. I have to say that I'm not. Big fan of Ripple, but

claire ripl 1:35

Ouch.

Callum 1:37

For me it's a kinder Eno

jame ripl 1:38

Wait, why did you invite them onto the show if you weren't a fan of them? What's going on?

claire ripl 1:43

I might just go,

Callum 1:46

Oh, I see The coincidence because Ripple is also in laboratory, 'cause I actually introduced it as the rare imported pathogen lab. So the dear listener wouldn't have known that we were talking about so what are we here to talk about today? So I guess the first question is what is Ripple I feel like we talk about that infectious diseases in the UK all the time, but what is a rare imported pathogens lab?

claire ripl 2:13

So, I can't really describe the thing that ties it all together, apart from we seem to be the lab that does the stuff that nobody else wants to do. So the range of things that we are responsible for diagnosing is all the way from the high consequence infections, like the viral hemorrhagic fevers, imported infections to things like Lyme disease, leptospirosis that you can just get, down the local river, or in the field next to you in the uk. So it's things that are either rare or imported or dangerous or difficult to diagnose. And it's bacteria and viruses. We don't do the parasites, so that all goes to, HTD.

jame ripl 2:59

And do you do fungi?

claire ripl 3:01

We don't do fungi as well, so I guess it's the. Rare, imported, unpleasant viruses and bacteria.

jame ripl 3:09

Non fundal. Non parasitic, very specific pathogens life. But I guess that's a bit difficult to, doesn't roll off the tongue as well, so,

claire ripl 3:19

Sometimes when we are if I phone up switchboards sometimes and say I'm from the rare and imported pathogens laboratory and they miss here and they think it's the really important pathogens laboratory, and it's yeah, we'll take that too.

Callum 3:33

And so that's what Ripple is. And I guess the other thing that we are here to talk about is the imported fever service, which I've certainly phoned and found very helpful. Maybe I could ask you, Amy, what the important fever service is.

Amy 3:47

Yeah it's the service which is adjacent to the rare and imported pathogens laboratory. So it's the clinical contingent. And so we provide 24 7 clinical advice and diagnostics predominantly for travel.

Callum 4:05

Line. Yeah, actually how busy is it as a line? Because I phoned it and it feels like you've all the time in the world to give us advice, but I'd be interested to hear like how many calls you get a day and how it, the workload is for that.

Amy 4:18

don't know if, I don't know if you have exact numbers, Claire. I know that we, there's two of us on call any given time, which is why there's often someone available. And yeah, it depends if there's an outbreak, if there's nothing of note going on, it definitely is variable. But we're on the phone most of the day. At least one of us is.

claire ripl 4:43

Yeah, so the Ripple doctors and the imported fever doctors are the same actually. So if you phone the Ripple lab and ask to speak to the doctors, you'll get the imported fever service doctors. But the imported fever service line is the one that's manned 24 7. So out of hours, if you phone the Ripple line, you'll just get, answer phone. If you phone the imported fever service line, you will go directly through to usually one of the consultants. But it is, the same clinical team. And we get, it's probably between five to 10 calls that's probably an upper limit actually, daily on the imported fever service line. But that does go up quite substantially if there's an outbreak. Or even doesn't even have to be an outbreak, just has to be awareness of something, um, outside the uk. And people are like, I heard about. This disease in this country, and now I think every patient might have it. So we do track it out. So during Mpox, particularly in 2022, every single, it felt like every single spotty person was seeing a doctor and being assumed to have like Mpox rather than the normal things like acne and chicken pox and insect bites and things. So we saw a huge rise in the number of calls.

Callum 5:57

We've certainly seen that recently with the unfortunate rabies case and, it's good that people are coming forward for vaccination, but you just wish that they'd had the vaccines before they traveled, but.

claire ripl 6:07

the rate is mad actually because it, there hasn't, you know, there's no change at all in the exposure. There's no change at all in the risk to the uk. It's literally just the awareness. So all of those people that are seeking vaccination or post-exposure, immunoglobulin, et cetera, are all people that should have been. Doing it, over all the last number of years and just haven't been aware. So there's obviously lots of people doing fun stuff with animals overseas all the time and just not aware that there's any rabies risks. It's been really, I mean, really helpful in bringing that to people's attention, but just not the greatest way to go about it. We don't deal with rabies, by the way. Actually, that's not, yeah, that's not us

Callum 6:47

that's important point.

claire ripl 6:48

Don't phone us About rabies. Not yet anyway.

jame ripl 6:53

So Amy, as the, doc who's manning the phone, at least some of the time, what's the sort of split of imported fever cases that are coming to you? Do you know the kind of stuff that the patient is eventually diagnosed with that you are, just being discussed?

Amy 7:10

So yeah, I am on the phone sort of nine till five, and then it's consultants outta hours and obviously the consultants are there all the time in the day. In terms of the calls are very varied. I think there's a lot of travel. Predominantly. I think a lot of the calls are people who have traveled to West Africa and a fair few have traveled to Southeast Asia. But I don't know if that's backed by data. It's just, it feels like that's a lot of the and lot of your flavivirus diagnoses and Alpha virus diagnoses. So dengue and chicken are a lot of the results that we call out. And I think each, on average, the most recent look back we do around one VHF test a week, from various calls that come through that might be direct phone calls or ones that we've caught on their way in as a triage. Where we think all this sounds a bit suspect we better give a ring before we test it. so yeah, that's also a,

Callum 8:20

Which is that key, like pre-analytic bit about identifying the patients at risk of VHF before you send sample to yourself. And we're going to talk about that in more detail in the next episode.

claire ripl 8:29

Can I just point out though, we don't like having a. On the phone, nine to five nonstop. We let her out for a very short lunch and occasionally let her do something else.

Callum 8:43

Yeah. So maybe this would be a good time to ask you, Amy, 'cause you're in this clinical fellowship role. So for those who haven't heard about that or perhaps have heard about it or interest in applying what exactly is that?

Amy 8:54

yeah. It's a great job. And I'm not just saying that 'cause Claire's there,

claire ripl 8:59

She needs a like posts fellowship review for her PYA or something, don't you? Amy, a RCP time.

Amy 9:11

I feel like I can speak freely. I'm coming up to the end of my time. So it's a year long fellowship, which you. Can apply for through the UK HSA. And it's just been a really wonderful year. I think you get the opportunity to work with an amazing team, very knowledgeable consultants, really impressive lab staff, and then lots of the research teams and other teams in UK

claire ripl 9:39

Keep

Amy 9:39

So yeah. Wonderful people. I am, when I was thinking about this, I was, I've awkwardly split it up. Do you know for part two, how we talk about doing the CLIP acronym?

Callum 9:51

Yeah.

Amy 9:51

it actually lends itself really nicely to the CLIP acronym, 'cause there's a lot of clinical work. So the telephone line that we've mentioned, the triages of samples and advising on testing lab wise, obviously working alongside the scientists in the Ripple lab and the consultant clinical scientist Jane, who is just the fonts of all knowledge who we get to work really closely with on understanding all the tests that go on. So I felt like my lab knowledge has, Exponentially increased, which is a treat. And we also authorize the pox cues, so the pox PCRs and the, Lyme serology, which is slightly more challenging as, yeah, it's definitely been a skill to hone in on. And then, calling out all the results that we often will call everyone about and then advise on infection control and PPE the country and category of transport and lab, safety. And then obviously the public health side of outbreaks. So been part of, I was trying to count and there's been quite a lot of outbreaks this year. So there was lasa, och, apo, Marburg in Tanzania, Ebola in Uganda, NEPA, and India. So there's been lots of phone calls and testing based around those things as well. So it's been really eyeopening and a lot of opportunities afforded because.

Callum 11:24

It's almost like the dream of the combined infection training, isn't it? You get to do the ID tropical side with the laboratory side.

Amy 11:33

It's definitely got a great combination, but I think they've, claire,

jame ripl 11:37

Kyle, can I ask

Amy 11:38

all made it to be that over time, so it's definitely, yeah, education wise it's been incredible. And obviously the teleconference as well, which is a good educational resource. So being part of that as well has been great.

Callum 11:54

Jim is trying, again, say something. I've got a question if he's, I'll come in with a question. So I think that segues nicely what you mentioned there, Amy, for a question I wanted to ask, which is just about I guess where, how did the ripple come across? Like where is it and what's the sort of like brief history of Ripple as a place? 'cause it's quite a, I think quite a cool history.

claire ripl 12:22

So Port and down started life as, a military facility. So came outta sort of military testing. Back in the day, when we were interested in developing bio weapons. And then after the bio weapon convention, when people decided that wasn't such a great idea, it sort of morphed into bio defense. And the site, and the sort of facility there, was then focused more on developing, countermeasures for the likely bio weapons. So instead of developing anthrax as a bio weapon, they focused more on developing a vaccine, and ways to test, for anthrax, and other potential bio weapons. And then, Because that's where it was. It then became the laboratory for testing the high co high consequence infections. So the things that needed a containment level for laboratory. And that was still, I think, all under sort of the military gus. But back in the sort of early eighties, if you needed somebody to have a viral hemorrhagic fever test, that's where you sent the sample. And then Ripple itself, came out in around 2012, there was a case, in London of somebody with lasso fever, who sat on a general medical ward because there wasn't any awareness of it, and there wasn't a straightforward way to refer samples for testing. And that case, it was a significant delay in the diagnosis, so about three weeks I think, and much of that time sitting in a general medicine open bay, until somebody thought about that as a potential diagnosis and then there wasn't a clear way of getting rapid testing. And so lots and lots of concern, and panic. And what came outta that was a, a. Was the development of Ripple. So I'm trying to think who it was because we've gone through so many iterations in terms of what U-K-H-S-A were. It used to be the Public Health Laboratory Service, then it was Health Protection Agency, then it was Public Health England. Now it's U-K-H-S-A. But it's the same thing really. I think it was, I think it was HPA back then, but then HPA was given the remit to develop this as an actual clinical service. And so the idea was that there would be a single laboratory with the responsibility for testing for these pathogens plus. Various other sort of travel associated, infections, alongside the 24 7 imported fever service helpline. So that people, if they suspected or even just didn't know and wanted to phone up and ask, I, got a patient and they've traveled to this country and I really don't know what to do. They've got a direct route, to people that deal with it day to day that are able to do the risk assessment. And then if testing's needed, it's a case of this is the sample, you send it to us, the laboratory will come in 24 7. So our lab staff, are on call as well. They can come in overnight or weekends to do VHF testing and to make sure that we didn't find ourselves in a similar situation, where. Patients go undiagnosed. The cost and the investigation of that was significant. I think there were several hundred staff patients, public potentially exposed. The crazy thing is that as far as we can ascertain, nobody actually caught LASA fever from that patient. But that was, yeah. Nobody got it as far as we know. So that was really impetus for the launch of Ripple as a sort of a, an entity. And alongside that, the imported fever service. And so as we said before, ripple's the sort of, the laboratory bit of it. And then the imported fever service is the, clinical interface. And along with the helpline, they also launched a multidisciplinary clinical meeting, whereby complex infection cases, particularly travel associated, could be referred in, and be discussed by a team of experts who would then advise on, the weird. Unusual infections. So it was set up actually and still is. It's a partnership with, the Hospital of Tropical Diseases in London, and the Liverpool, tropical and infectious Diseases unit. So they are part of our rotor. Uh, and they contributed to the MDTs when they worked like a sort of a an MDT that's morphed now, into the IFS teleconference. So it's much more a teaching platform. But the helpline is still there and still manned, by a mixture of Ripple, HTD and tropical Infectious Diseases Unit. TIDU, from liver.

Callum 16:51

You have to say, having phoned from the other side, it's been very helpful. Whenever we've managed to whenever we've had someone that we've needed to phone about. And I guess the other thing that's worth highlighting, which are in the show notes that Amy has very kindly put together for us is the excellent ripple user manual. So that's another great reference point just to see what tests are offered and it gives a lot of advice on how to do that. And we've also got a link to a website which gives some more details on what the imported fever service is and how to contact them, phone numbers, et cetera. Which is, surprisingly straightforward to be honest. So I guess that's good.

claire ripl 17:25

So the manual with. Tidying up at the moment and trying to make sure that the things that are listed there also will link out hopefully in the next few months to more information about, the epidemiology and the clinical feature of the disease. And the other thing to mention is that's what we admit to doing in the manual. We have access, not necessarily done by, the Ripple team themselves, but we have access to other testing at the port and site, in sort of research assays for some of the even more esoteric stuff. where there isn't a readily available assay that we are going to use frequently, we still have access. So if you think it's something weird and it's not in the Ripple manual and it's a virus or bacteria still don't do fungi, or parasites, but yeah, call us anyway. And we've potentially got access to secret testing.

Callum 18:14

And then I guess just for people that are wondering my, so if it's a a rare path at parasite, then that would go to the

claire ripl 18:24

hospital for tropical diseases or else the, in the tropical infectious diseases unit, in Liverpool. So both of those provide parasitology? Yeah.

Callum 18:33

would go to Bristol or Manchester depending on what it is.

claire ripl 18:38

Actually, can I just, so that's a good point. So we do the primary testing for the uk, but there is a sort of a, there's a partner laboratory in Edinburgh as well that does the VHF testing. So that if you're an inverness, you're not waiting two days. So that's probably good for people, north of the border to know. So the testing is still through the IFS, so you still phone the IFS and then instead of activating the port and lab, we'll activate the Edinburgh lab. And they offer the same sort of service for the viral hemorrhagic fever. So they'll bring in their team outta hours if necessary. And they do the same tests, as Ripple. They don't do all the other s serological diagnoses that we do. So if it's negative on the PCR testing that they've done, they'll usually send it then down to us for confirmatory testing and then for all the sort of onward investigations to see if we can figure out if it's not Ebola, what is it?

Callum 19:34

So I've taken the sample from my web browser returning traveler, and I'm going to send it to you and I've got the nice request form that's on your website. Now, what are some of the issues that you see? Because I feel like for myself, looking at request forms from my, the users of the bude I work in there's often issues with that pre-analytic phase. So what are the common issues that you see on the request forms to yourself?

claire ripl 20:03

So the first thing I would say is, please, can you fill out the request form? It's got some prompts there. It's got a little box for free text if you want to, if you want to wing it. But just put something, put something sensible on there. I know it's a bit difficult because, it's not always the clinician who's filling it out. So quite often they'll have, you know, hospitals will have their internal limb system that will put, generate the request and then the lab will print out a form what the lab put on that form. Very often bears little resemblance to the actual. Clinical picture or they don't fill it out, or they just put travel, and it will delay basically the result. Because what will happen is if there's no information there, we will just not process it. And you'll just get a grumpy message when you look up the result that says you didn't ask for anything. We didn't test anything. It's slightly lighter than that, but that's the message. And it's really helpful to do the VHF risk assessment before you send the sample. So if you can say VHF risk assessment completed, not a risk, that means we'll just go ahead and process a sample. If you say travel to Nigeria Fever. We don't know whether you've even thought about Lassa or not. And that would be, a major concern. Our laboratory won't process that sample until we've made sure that risk assessment's done. 'cause we need to know, A, should we test it for Lassa and B, is it safe to handle we don't actually process these samples at containment level four. They're processed at containment level two, but in a class three cabinet. So it's quite a faf, for the lab staff to handle them. So they need to know what level, what containment level they should be handling the samples at. So if you put, Nigeria fever, amy or one of her colleagues will phone you, will track you down, and make sure that's completed. So the ideal thing we would love electronic requesting, but I, I need a fairy godmother or something apparently to make that happen. But until, and unless we get that. If people can actually print the form out themselves and fill it out and then send that with the sample to the laboratory, then that's what should come to us, and that would be the best way of making sure we get the information. I know that's not always possible, but that would be really helpful. I was actually just looking up because I, we do actually keep, a mini catalog of the fun requests that we've been sent. And I was looking for some examples. We don't, we don't, publish 'em on the website, but we may possibly occasionally use them for like port and down site Christmas quizzes, where we show examples, of poorly filled out forms and things that people have asked for. There's some real howers, like, oh, okay, this wasn't actually request form, this was an actual query that came through. But it's the sort of thing we will sometimes see in the request form. So somebody phoned up because a person had been in Mauritius and something had flown over their heads and then some liquid went in their eye and from all of this, they deduced that it was fruit bat guava or something that had got in their eye and then they were concerned. That's the sort of thing we do sometimes see on our request forms. And they're just like,, I don't even know what, I don't dunno what to test or I, I don't really know where we're going with this. But yeah, we do get some really wild stuff.

Callum 23:18

That, that kind of reminds me a bit of the the Speaking Parasitology which I used to listen to a lot, and they would come up with these like reso really esoteric stories about someone eating, like putting a of frogs in their eyes and getting some strange parasite, yeah. It's hard to, sometimes it's hard to know with these rare things. Like

claire ripl 23:34

Well, some,

Callum 23:35

in the back of my mind, like people tell me strange stories like that and I think, but what if there is something I dunno

claire ripl 23:41

well, that's the thing. The thing is this is the mad thing about this job and about. Infectious diseases in general, is that sometimes it is the weird exposure and, sort of part of the job is just finding the one weird question that hasn't been asked that like, leads you down that route and you'll hear it. Like, I, I do enjoy being in the office sometimes and just hearing the questions and it's do you know what species of bat it was? Because that's actually important, you know? Look, he's got a t-shirt with bats on. You need to come and work for us and you can like, you can be like the visual cue for callers and we'd be like, point to the bat that you think defecated in your eye.

Amy 24:21

But there was a question a couple of months ago now, which was that somebody had eaten I think it was bat soup, actually, to stay on the bat theme. Was, we basically needed to find out how it was cooked, because if it was very well cooked, then it's probably fine, but if it was maybe just a bit suspiciously boiled, we needed to have a bit more of alarm bells ringing. Yeah the questions are important. Definitely important.

Callum 24:49

So if I did have this patient that I was seeing and had, let's say, traveled and had been to. Let's say Uganda for just, but anywhere the general approach. So we send you the sample I filled in the request form with as much

claire ripl 25:03

Thank you,

Callum 25:04

can. I put the font very small so I can fit lots and lots of information into that little box. What's approach testing? Because what I find really interesting is it's not, like I say, guess you, my understanding is you can request a specific test, but most of the time we're sending what, like geographical panel is what my understanding is that I don't really understand what happens when that gets to you. Like how do you actually approach and decide what you're gonna test on that sample?

Amy 25:34

So if the sample just comes in without discussion, then it gets put through coding. So that's, through the consultant clinical scientist and through senior biomedical scientists who essentially do the triage and the coding based on the place of travel. Predominantly. So that's for your geographical panel testing, but obviously also the exposures that might have been documented. Hence why the more filled in the form. The better because then you get more specific testing then there's a decision based on whether or not PCR is added or if it's just serology. So that depends on the dates of travel versus the onset of symptoms. So again, why that's also important to fill

claire ripl 26:21

Just to go back to the form, it doesn't have a tick box about the VHF, but what it does have is a big box that says if A VHF or infected with another hazard, group four pathogen suspected, please phone this number in big, bold letters.

Callum 26:37

This podcast and realize that you're not scary and that it's

claire ripl 26:41

Oh, we're doing this all wrong

Callum 26:45

It's okay to phone you to say that they've done the VHF risk assessment. 'cause I honestly not sure. I think I might back put that on the form, but I guess I hadn't realized that was, it is kinda obvious now that you say it, that it's important to, document. Yeah, it's really interesting to understand how you doing the testing. And there's again, limitation of podcast setting, but there is graphic in the show notes, which are linked in the description, which has the different geographical areas, color coded. Quite like the colors on it. It's just quite a pleasing map actually. But, yeah, that

claire ripl 27:16

You are welcome.

Callum 27:17

how you do the geographical panel and it's from the user manual, isn't it?

claire ripl 27:21

Our. Predecessors in that they did all the hard work back then in developing those geographical panels. So they went through all these different regions of the world and said this particular area has these pathogens that are of interest that we can test for. And so what we'll do is we'll say if you've traveled to a country within this area, these are the things that we'll test you for. All that hard intellectual work went in then. And now we are quite lazy. We're like, they've been to Kenya, that's in Southern Africa, so that gets our Southern Africa panel and that's got this. We do review them, so we do keep them under review and make sure that, so things are added. It's quite hard to take things off because unfortunately diseases don't go away. More diseases come, so our panels tend to expand. Over time. But yes, there's been a whole lot of epidemiological work behind that, and we do it to some extent. So most of our testing is based on the sort of geographic, the travel history. We a, trying to nuance it a bit with the clinical picture as well. So we have an internal encephalitis panel of the things that we do that are relevant for encephalitis presentations. So that doesn't appear in any of our sort of guidance, but it's a sort of an internal thing that we do that we'll try and develop further.

Callum 28:43

So I was going to ask, that kinda leads into the question, so we're seeing, climate change related spread of some pathogens, which we might not traditionally expect to see in the areas that we're now seeing them. With the change in vector distribution places that come to mind be like Spain, Southern France seeing local transmission of malaria. How does that affect your geographical testing? I guess that's what you mean by keeping things up to date.

claire ripl 29:12

Mm-hmm. Mm-hmm.

Callum 29:13

I've got a fever and turning traveler, and I think that's one of the problems I see is that like when I talk to or patients that're traveling, and people go to areas in Europe, they don't necessarily think that there's a travel associated risk, going hiking in the in Czechia or going on a beach holiday in southern France, it might not necessarily associate the same degree of risk as you would with going on safari in South Africa. Even if the risk is there. Yeah, I guess is that influencing your, is that something that there must be a bit of a challenge to keeping track of where these are in specific geographical locations, but also like people potentially aren't even sending the tests when they're indicated.

claire ripl 29:57

There's definitely an ascertain aspect to it. And it, as you say, if people aren't aware, they're not gonna know to test or even to think about sending samples anywhere, let alone ripple. So. I mean, we test what we get and we try and raise awareness, through presentations, through the teleconference, through things like this podcast, to let people know that we exist and at least to signpost them to the guidance and to say, look, if you're unsure, just send us a sample with some information and we'll sort it out. But yeah, we, we've added, dengue to our sort of Southern Europe panel, recently. So once that sort of, once we started to seal toxin this case, it's kind of annoying. 'cause like I say, the panels keep expanding and you're like, Ugh, one more test we've got to put on this. But yeah, so we keep, we try and keep abreast of that. I mean, there's other bits of U-K-H-S-A who do, surveillance alongside us. So there's a, a, emerging infections in zoonotic surveillance unit that will alert us, you know, if they see something published in the literature, if we haven't seen it already. So yeah, there's various ways of trying to keep abreast of it. And we get alerts from WHO or from ECDC, et cetera. And then we'll take a view internally about whether this is something that we add. I, I mean, there's a bit of diagnostic stewardship that, that comes into this. I think it, it's poor practice and it's quite clinically lazy and we are very guilty of that just to test everyone for everything. So we always we, when we're adding the test, we take a view as to, do we do the most likely things first and then do this as a sort of second line testing? Or do we just say. They'll get an answer quicker if we do everything all at once. So it's just finding that balance. So for an example, oropouche has emerged in South America and that up until recently, was very rare. So occasionally we'd come across cases where they were negative for dengue and the usual arbovirus viruses. Jane Osborne is going to tell me off saying Arboviruses, but everybody else know, knows what I mean. It's not really a class of virus and she gets quite exercised about it. That's our clinical scientist.

Callum 31:57

I, I say arbovirus, so.

claire ripl 31:59

I say it all the time and every time I just hear her in my mind going, Gordon, stop it. Um,

Amy 32:05

flabby virus is an alpha viruses. 'cause I was like,

claire ripl 32:07

I know,

Amy 32:08

possibly say.

claire ripl 32:09

I know, it is. Oh, Ainleys on fire tonight. So yeah, so Afu is a mode we'd normally test for other, insect ball. Viruses, and then only occasionally go, it still sounds a bit like auch and it's negative for everything. More recently, as that outbreak has expanded geographically and we've seen cases now imported into the uk. So we are starting to test that frontline, if, if people are presenting with the right syndrome. So we'll do it, along with the dengue. So

Callum 32:38

Yeah, that's interesting to hear the insight. 'cause what I've experienced is, so what worth mentioning here is that usually my understanding is the sample type that you want is like a serum sample. But urine can be quite useful. So sometimes we've had results really quickly from patients that have returned and you phone us up to say they actually done a PCR on a urine and found is it dengue that you do in urine? Yeah. And that's it is surprising actually. 'cause sometimes you're getting the test results back really quickly and it's just really helpful. It often, supports your clinical suspicion and you can stop investigating for other things.

claire ripl 33:11

So we run most of the PCR testing daily actually. So if there's, and if a sample is with us before eight o'clock in the morning, it'll be on the PCR run that day and you'll have a result phoned to you if it's positive by five o'clock. So we, yeah, we try and we try. So even though we're, geographically distant, we try and meet similar turnaround times to what you'd expect if you'd just sent it to your hospital laboratory. So it's just, if you can persuade your lab to send the sample to his asap, it'll be tested.

Callum 33:37

the administrative burden of a sample to you is probably the hardest bit. And you don't have to answer this, but one question I have is what's the, how is Ripple funded, because, we do these tests locally, it's very expensive, and so there's often a lot of hand wringing about doing stuff. How does that work? Do you charge the, referring laboratory for the sample? And how does that sort of, 'cause it seems I don't know what the cost is, but it doesn't seem that expensive for all the work that you do. So I presume that there's some central funding as well to subsidize that.

claire ripl 34:09

Yes. So there's core funding that. Goes into the background work. So developing, tests, particularly for rare pathogens that, as you can imagine, is quite expensive and quite labor intensive if there's not a commercial assay that you can buy off the shelf. So again, there's a whole, diagnostic development department, that. Do the assay development, and workups to bring them into Ripple. So that. Is outta central UK HSA funding, but the actual Ripple laboratory testing, most of it is charged for. And again, we benchmark the sort of the charging with NHS or other reference laboratories. So it shouldn't be too expensive. And in order to encourage the panel testing, we do a sort of a three for two, type offer where if you ask for two separate tests, you'll be charged for those two tests. If you ask for three tests or more, you are charged the same. so it shouldn't cost. So a single test on its own, will cost you, I don't know, I'm gonna make up some numbers now, but that'll cost you about 80. If you want three tests, it'll cost you 120. If you want four tests, it's 120, et cetera, et cetera. So we don't additively charge, once you get to a three test level so that Yeah. And I think that's possible partly because of the core funding, but, um, we, some of the tests obviously aren't terribly expensive. So they're standardized. We tend to standardize the testing and some of our testing's quite high throughput. So Lyme disease, lots and lots of testing that kind of pays for itself. We've recently introduced Barella testing, which kind of pays for itself, just with the sort of, I know, right? Are you excited?

Callum 35:51

Bartonella testing has been like such a difficult area and it's not that unusual, to be queried that, a cat scratch disease, wow. And is that serology and PCR or,

claire ripl 36:04

Yeah, so we've actually always done PCR, but obviously not everybody gets a decent biopsy, which is the sample that you want. So now we've brought in a serology to compliment that after much requesting we, you, you said we did.

Callum 36:19

Wow. That's exciting.

Amy 36:22

pan, PCR, isn't it? And then, serology is Bartonella Hensley,

Callum 36:27

So not

Amy 36:28

serology.

Callum 36:29

Quintana, is that it?

claire ripl 36:32

yeah.

Callum 36:32

fever?

claire ripl 36:33

Yeah.

Callum 36:33

Yes. and vaguely remember this from my DTM and H days. that makes sense.

Amy 36:39

Also

Callum 36:39

think,

Amy 36:40

As an, just to add to the last bit, because the costs for tests are also in the user

Callum 36:47

oh, of course they are.

claire ripl 36:48

They are.

Callum 36:49

Yeah. Vague. We thought. Yeah,

Amy 36:51

just say.

Callum 36:53

we,

claire ripl 36:54

Yeah. And, and the numbers I've quoted are just made up. Look at the user manual. It'll give you, don't come at me.

Callum 37:01

So I think we've covered most things. You're doing so much stuff that's really helpful At Ripples, you've got the laboratory, you've got the imported fever service, you've got the MDTs you've got the teleconference weekly on a Tuesday at quarter past to GMT which is really useful. And actually on top of that, you send out these emails afterwards, which I have to admit, I don't often manage to come along, but the emails come with this beautiful summary of the case and the learning points. And I think for continuing professional development it's amazing because I can read that or if I'm like, thinking about something, I just have a folder in my emails that I've saved all those emails. So I can just go into that and search. And it's like a really useful way for me to get some quick notes. So for putting all the work into that. So if that wasn't enough what else does Ripple do?

claire ripl 37:52

We've got the diagnostic stuff. So I, the sort of overarching summary is that we do the diagnosis of the imported and high risk infections, and then the common infections, imported in travelers, and then diagnosis and surveillance of native infections. So the Lyme disease, leptospirosis Q fever, diseases. We also have, a surveillance, arm for those. Looking at the prevalence in the uk, the risk factors in the uk, looking at, potential. Control methods, and, raising awareness particularly for tick-borne diseases. and then there's also work that we do with, the entomologists, the medical entomologists, at Porton, looking at the risks from,, from vectors. So there's two bits of that. And one is existing vectors in the UK that might become infected with particular pathogens and then also. Invasive vector species that may come to. The UK and set up, and then be capable, of transmitting disease. So we work with them to help do the risk assessments, and sometimes, some of the testing, et cetera. And then there's other bits and pieces of research and development where WHO collaborating center, for special pathogens. We've got research connections, with, Liverpool for emerging and zoonotic infections. So for the clinical fellows, we try and get them involved in bits and pieces of that, whatever takes their interest really. So particularly if there's been an incident, a new case, of something that's been first recognized in the uk, then the poor old clinical fellows get sucked in, to some of the work Amy, has there been something that you've really enjoyed, which been your favorite

Amy 39:38

Oh,

claire ripl 39:39

bit?

Amy 39:39

favorite, I don't know if I have a single favorite bit, but things that I, in a really nerdy way would like to talk about would be there's the development of the metagenomics service, which is happening at the moment. So for fever and the returning travelers, so. as clinical fellows we're involved in helping set that service up, which has been exciting. And then, we are in the process of doing sort of a lasso series surveillance study which is ongoing, which has been amazing to be part of

Callum 40:19

Wow.

Amy 40:20

serious surveillance study. When do you, Do you get to do that? That's been great. And then yeah, some world Health Organization collaborations as well that we've got to be part of. And then, I don't know if everybody has heard, maybe they have, but there's been a confirmed case of Francis um, in the uk. And so that call came through when I was on call. And so it was, yeah,

Callum 40:49

Wow.

Amy 40:49

really interesting to be part of that as well and how, happens next sort of thing. How do they decide as a UK health security agency, what happens? How do we assess the risk for the uk and also then how do you clinically manage the patient who's in front of you? So that's been really I, that was more than one, but it's been a, it's been great, as I said.

Callum 41:14

That's a lot of stuff and really exciting. And how would people learn more. So how would you beyond this podcast, is there any avenues that people could find out more about Ripple or get to go to Ripple?

claire ripl 41:28

You can apply for a clinical fellowship post. So we have, usually one clinical fellow a year. Usually August till August. And, that's advertised usually in January, February time. And we'll alert people on blue sky and on the IFS teleconference when that adverts, coming out. We run training days, usually once or twice a year for senior resident doctors, so infectious diseases, micro viral trainees. And we also do a clinical scientist training year, and that's usually, Clinical scientist training day. And again, that's usually once a year, and those book up very quickly and they're usually advertised on the teleconference. And again on Blue Sky. So the teleconference is probably the first place that people hear of them, and they're almost always filled up at that same day. So you do have to keep alert, to find out about those.

Callum 42:17

And to sign up for the teleconference, we've got the email on the show notes so you can go there and email to, to join up.

Amy 42:23

The other way that people can experience ripple, I guess is through the ESCMID Observership as well. so it's an ESCMID Observership which means that you can apply through ES as a sort of, I think it's a young scientist trainee, and can apply to spend a week to however long with ripple. And as trainees, as clinical fellows at Ripple, we then get to go on ESCMID observerships elsewhere. So one of my colleagues this year went to Chile, for three weeks, And I went to South Africa for three. So it's a good sort collaboration

Callum 43:08

yeah,

Amy 43:08

as well.

Callum 43:09

So we've covered so much there. Really fascinating. So just to run through and summarize what we've heard about. So we heard about who Ripple are and about the IFS, where they are and the history of how it came to be, they do. nobody else wants to do sometimes. And it's bacteria and viruses. We heard a little bit about how to be excellent at requesting a test from Ripple and how they approach deciding what tests need done on the sample and what tests are available. One thing that wasn't mentioned was it's very important to give a vaccination history because that can affect the serological assays.

claire ripl 43:51

You have been paying attention. Thank you.

Callum 43:54

I was literally thinking about that today because I got a request back

claire ripl 43:57

You've been getting with comments? Yeah.

Callum 44:00

for tickborne Encephalitis and Yellow Fever. And I hadn't seen the patient and I was like, they vaccinated? I didn't know yes. I'm not taking the blame because I didn't request it. And we heard about how to interact with with the team. So you can phone the IFS or you can phone Ripple but the same people spoilers. And you can email as well. And there's obviously the teleconference weekly and all the other excellent things that you're offering to everybody. Listener to the podcast are not. but if you do say that you listen to the podcast, you will get preferential treatment.

claire ripl 44:33

Definitely. Just put it in your application for an open day.

Callum 44:38

Great. Thanks very much and I am, I have no doubt that this podcast episode will send ripples for the infection community.

claire ripl 44:47

Brilliant.

Amy 44:48

Thanks

claire ripl 44:48

You got it in.

Amy 44:49

us.

Callum 44:50

Thank you, bro.

claire ripl 44:51

Thanks very much.