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December 2002 As has been our custom, the members of the editorial board were again asked to vote on what each of them considered to be the 10 most important subjects covered in Infectious Disease News during 2002. The list is as follows, presented in no particular order, since we would not presume to rank them:
Several of these topics have appeared in previous year’s top 10 lists, but the subjects have developed further or been expanded. Examples of this are bioterrorism preparedness, the two HIV/AIDS topics, and vaccine safety issues. Others, such as VRSA and new approaches to hand hygiene are quite new to the list, even though in both instances we could (and did) predict their occurrence. Space will not permit extensive comments on each of these topics, but a few comments on some are in order. The smallpox vaccine recommendations have, at this writing, still not been released; they evidently await a presidential decision attempting to balance risks with potential benefits. The two options that seem to remain viable are broad immunization of health care and first-responder personnel and making immunization available to all that desire it. A third option is to recommend both, using the experience gained while carrying out the first option to guide the procedures used in the broader program of the second. Recall that it was only six months ago that the ACIP recommended a very narrow program of vaccinating selected health care teams in each state, a recommendation endorsed by many professional organizations, including IDSA. Assuming some vaccination gets underway next year, there will be many challenges for infectious disease physicians and hospital epidemiologists in planning and supervision, as well as in management of inevitable complications. Each hospital will need to develop their own strategy and policies to carry this out. Many health care personnel are likely to decline vaccination, especially in the absence of smallpox cases and hospitals must allow individual choice to their personnel. Should those recently vaccinated, who may still be shedding vaccinia virus, be allowed to care for immunocompromised patients? Should they be furloughed until the lesion is scabbed over? If so, who pays for their time off duty? Thus, it should be anticipated that there will be a plethora of issues to resolve at the hospital level. Another issue to make the list is the issue of activated protein C. Since this was extensively discussed in last month’s issue, little more needed to be written now. It is clear that Eli Lilly is devoting enormous resources to sepsis education and product promotion. Lilly likely believes that the window of opportunity for their product, drotrecogin (Xigris) will be measured in a life span of perhaps 3-5 years before it is succeeded by 2nd or 3rd generation sepsis response modifiers. Vaccine safety issues, a frequent top 10 story in the past, was prominent in 2002 as well. The IOM Vaccine Safety Committee continued its ongoing efforts to evaluate all aspects of vaccine safety, and issued reports that generally affirm that recommended vaccines are safe. Yet in following scientific rules of evidence, sometimes they have stopped short of full reassurance. It is, after all, logically impossible to prove a universal negative. Evidence was judged inconclusive on several key issues such as multiple immunizations increasing the risk of allergic disorders (such as asthma) and cancer caused by SV40 containing polio and adenovirus vaccine. It is not surprising that the many anti-vaccination groups remain unconvinced, in spite of scientific reassurance from the IOM.
Another vaccine issue in the top ten was the striking success of the pediatric 7-valent conjugated pneumococcal polysaccharide vaccine (Prevnar, Wyeth) in preventing invasive pneumococcal disease in children. The report, however, noted that the rate of invasive disease in adults dropped as well, suggesting perhaps children were acting as a reservoir for pneumococcal infection in adults. However, a search for data to support this contention has proved fruitless so far, and this may represent more of an optimistic hope at this time, rather than an established fact. In the meantime, before a conjugated vaccine for adult use becomes available, there is emerging evidence that optimal protection of the elderly may be achieved by using both vaccines in that population. HIV/AIDS issues remain in the top ten of course, as they have been continuously. The increased frequent introduction of more potent and even more “user-friendly” antiretroviral drugs is clearly having a major impact on life expectancy. One unintended consequence of this generally very good news is that AIDS is seen less and less as a death threat and rather more as a chronic disease that can be managed. Perhaps this explains the apparent decline in testing of persons who likely know they may be at risk, but have not yet come forward. At the global level, the grim litany of numbers of cases and deaths continues seemingly unabated, and there is substantial underfunding of prevention efforts. Yet, there are occasional successes with focused prevention efforts in a few countries. Whether these successes can be sustained remains to be seen. Finally, the new hand hygiene recommendations from CDC seem to be the final chapter in what has been a remarkably rapid change in hospital infection control recommendations during the last three to four years; “hand-washing” is out, effectively ending a 50-year mantra — “hand hygiene” is now in. A topic I thought was important that never made it to the list, probably because it hadn’t yet appeared in print, was the Smadel Lecture at the IDSA Meeting, presented by Dr. D.A. Henderson. His topic was “Disease Eradication: Lessons Still Unlearned,” and it proved to be a very thoughtful presentation from someone who has faced the issues before. D.A., who himself directed the WHO smallpox eradication effort, expressed his reservations about ongoing and future disease eradication efforts. Eradication of poliomyelitis and measles, given what we have learned in the past 10 years, might prove so demanding of resources that we might accomplish much more by backing away from the goal of eradication to seek the lesser goal of “control,” and using the resources saved for other pressing public health needs.Looking forward to 2003, we can confidently predict that many of these topics will remain major issues; one need only think of smallpox vaccine for health care personnel. Happy New Year! |
