The top 10 stories in 2004

December 2004

As has been our tradition in the past, Infectious Disease News editorial board members were recently polled to select the top 10 infectious disease news stories for 2004; these are detailed elsewhere in this issue. Regular readers will be aware that some of these topics also appeared on last year’s top 10 list; recurrent topics this year include severe acute respiratory syndrome (SARS), influenza, emerging infections, antimicrobial drug resistance, and, of course, HIV/AIDS-related topics that appear in every year’s top 10. No attempt was made to rank order the 10 “winners” of this dubious distinction; hence I will discuss only some of them as space permits, and in no order other than my interest in further comment.

Increasing antimicrobial drug resistance has been a leading story in infectious disease ever since Infectious Disease News first began publication. Even during the 1960s and 1970s, leading antibiotic investigators such as Maxwell Finland were warning of the indiscriminate use of antibiotics and emerging antimicrobial drug resistance. It is obviously not a new story; yet it is possible to believe that this year has been different, and that the public and our elected leaders are sufficiently aware of the growing antimicrobial crisis that constructive action is likely to occur.

There are a number of reasons to hope for change. The CDC’s initiative to reduce the inappropriate use of antibiotics is clearly having some effect, both on patients and prescribers. The paucity of new antimicrobial agents in the R&D pipeline is now well publicized. The emergence of new antimicrobial drug-resistant pathogens, eg, penicillin-resistant pneumococci, or old drug-resistant pathogens in new settings, eg, community-acquired MRSA, has clearly alarmed both the infectious disease community and the public. Publication of the IDSA document entitled “Bad Bugs, No Drugs” has had a significant impact on both legislative and executive branch thinking in Washington. Finally, the threat of bioterrorism has also played a role, and the BioShield legislation will aid in the development of both new antimicrobial agents and vaccines against both natural infectious disease threats and potential agents of bioterrorism. I have already commented editorially on the IDSA “Bad Bugs, No Drugs” campaign, and I continue to believe it to be the most important public policy initiative ever undertaken by the IDSA. It must be kept on the front burner in Washington.

Influenza dominates

Three of the top 10 topics deal with influenza; little did we realize that such a common entity could command so much public and professional attention! The three topics are (1) release of the long-awaited pandemic preparedness plan; (2) the continuing spread of avian influenza; and (3), of course, this year’s vaccine debacle. With regard to the last point, it is ironic that this was the year we all thought we had it right: the right strains in the vaccine; more vaccine available (>100 million doses) than ever before, and thus plenty of vaccine to support new initiatives in influenza immunization of children; and lowering the “at-risk” age from 65 to 50. All that vanished overnight, of course, with the news from Chiron, and suddenly, the people at “high risk” were waiting in endlessly long lines for short supplies of vaccine. By the time of this writing, the panic has subsided, vaccine supply has been redistributed to areas of real shortage, and most of the “high-risk” that could be reached have, in fact, been vaccinated. Many states, including my own, now have unused vaccine waiting to be used.

This entire experience, however, has underscored just how fragile our vaccine supply really is and how unprepared we really are for an influenza-related emergency. The problems have finally been recognized at the federal level, and we may yet have reason to be grateful to Chiron for so vivid a demonstration of the problems.

Pandemic protocol

The influenza pandemic preparedness plan was released for public comment, and although it is seemingly comprehensive, a great deal of detail remains to be filled in. Both the IDSA and the Society for Healthcare Epidemiology of America have seen fit to provide comments, and these are available on the individual Web sites for those who wish more information. All such feedback documents begin with pro forma congratulations and commendations to the authors, of course, and then proceed to identify some of the obvious gaps needing to be filled in. For all the years this document has been gestating within the federal government (about a decade), one might have hoped for a more mature document than actually emerged. Nonetheless, it is a start.

The pandemic threat posed by the H5N1 avian influenza viruses continues to haunt us. Spread within avian populations, including ducks, continues in Southeast Asia, apparently unabated, and with a gradually expanding host range, now including pigs. This is significant since pigs are susceptible to both avian and human influenza viruses, thus affording ample opportunity for genetic mixing and recombination to occur. Save for one unusual instance of possible spread within a family residence, there has not been sustained human-to-human transmission. Among the approximately 35 to 40 human cases, however, the mortality rate has been an astonishing 65% to 70%. Almost surely this is artifactually high, due to undocumented nonfatal human illnesses, but nonetheless this level of mortality is alarming. The estimate of worldwide deaths that are widely quoted are based on these data and, in a worst-case scenario, amount to 100 million pandemic influenza deaths, a population-adjusted estimate comparable in severity to the 1917-18 pandemic.

SARS gets scarce

One of the unsolved mysteries in this year’s top 10 stories is “whatever became of SARS?” In 2004, the several cases of SARS that did occur were all laboratory-related; no “natural” (whatever that is!) cases occurred, and there was obviously no “natural” spread. Will SARS remain confined as a laboratory-acquired pathogen, or will it emerge at some future time from the same environment in which it came in the first place – or even some new and unsuspected environment? Only time will tell. Is it possible that what now seems to be a public health triumph may someday prove to be an aberrant event lacking adequate explanation? We would do well, however, to remain alert and prepared for a reappearance of SARS.

Space does not permit further detailed comment, yet there are other important topics to cover, including the emergence of community-acquired methicillin-resistant Staphylococcus aureus infections; the transmission of rabies through solid organ transplantation; mad cow disease in the United States, or rather its continuing absence after one case a year ago; and others. There were many facets of HIV/AIDS news, many representing real progress and others detailing continuing failure. It is likely that some of these topics will emerge further in the year ahead and merit further comment at that time.

Meanwhile, best wishes to you, our readers, for the coming holiday season and the New Year! 2005 promises to be at least as interesting as was 2004!