Old and new stories top the 10 stories of the year in Infectious Disease News

December 2005

In a tradition going back almost a decade, the December issue of Infectious Disease News always reviews the 10 stories judged by the editorial board to have been the most important infectious disease news stories during the year. The top 10 stories for 2005 — listed more or less in the order of my own interest — are as follows:

• Avian influenza
• CA-MRSA
• Adolescent vaccines, acellular pertussis and meningococcal vaccine
• A new, more virulent strain of Clostridium difficile
• Largest recorded Marburg outbreak ends
• New antiretroviral drugs this year, plus what’s in the pipeline
• HPV vaccine shows good efficacy
• VZV vaccine in the elderly reduces shingles
• Universal use recommended for hepatitis A vaccine
• An overview of “regular” seasonal influenza

Two points emerge from an inspection of this list. First, it is clear that some of these stories are on the top 10 list year after year, (eg, antiretroviral drugs and influenza vaccine). Other stories last for several years before dropping off the list. Second, six of the topics relate to or involve vaccines! This is in part a reflection of the great progress being made in vaccinology, and also in part, truthfully, a reflection of my own interests.

Space will not permit extensive comment on all of these topics, but a few words about some of them are in order, however.

Avian influenza

Last month’s editorial on this topic was written just a day before President Bush’s announcement of his pandemic preparedness plan. I was transiently worried that my comments might need to be modified. Not true at all! The Bush plan is fine as far as it goes, but it does not go far enough in supporting global surveillance, or in helping states acquire adequate supplies of vaccine – if and when they become available – and anti-influenza drugs. Little thought or planning was given to global needs for vaccine in the event of a 1918-style pandemic.

Of great interest was the complete reconstruction of the 1918 virus by Jeffrey Taubenberger, MD, PhD, and colleagues. The viral genome was found to be almost surely of avian origin, with little evidence of recombination with swine or human viruses. That sobering reality supports the need to study closely the antigenic changes occurring with the current highly pathogenic H5N1 avian virus. At the same time, I am somewhat bemused by the number of “experts” who appear regularly in the public media and predict – with virtual certainty – that H5N1 will be the next pandemic strain – and soon! Lifelong students of this disease are much more humble about their predictions!

Universal use of hep A vaccine

It took 15 to 20 years for hepatitis B vaccine to move from an initial target of high-risk groups to universal use in infants. The same is now proving true of hepatitis A vaccine. This broadening of the hepatitis A target was predicted years ago by a number of people, including the undersigned. This lapse of time is not intended as a criticism, far from it. The years have established a record of safety and efficacy that now permit a move to universal use with a great deal of confidence. (Recall the rotavirus vaccine story for an object lesson in the potential dangers of moving from licensure directly to universal use.)

Adolescent vaccines

Both Sanofi Pasteur and Glaxo-SmithKline’s Tdap vaccines have been approved for use in adolescents, and the former for use in adults up to 64 years old. Beyond the obvious need to immunize adolescents, there is now an equally obvious need to address immunization of health care personnel. Health care personnel who provide care to infants, children and adolescents are clearly candidates for this vaccine, and all patient care providers in primary care settings are candidates as well. Individual hospitals might elect to target other groups as well.

The ACIP recommendations are awaited with interest. Sanofi Pasteur’s conjugated meningococcal vaccine, Menactra, is a major improvement over the polysaccharide vaccine, and is strongly recommended for individuals going to college.

The recent appearance of five cases of Guillain-Barré syndrome in five patients two- to four- weeks post-vaccination is of concern, but this has not yet reached the threshold of altering the recommendations for use, since more than 2.5 million doses have been administered.

VZV vaccine reduce shingles risk

The varicella zoster virus (VZV) vaccine was an important story this year, and may be one of the few to be non-repeating. The questions that remain are: Will the FDA approve the license application on the basis of this single, albeit definitive study? How will it be priced? Will Medicare and the Veterans Administration cover the costs?

When all of these questions are answered, VZV vaccine given to adults aged 55 to 65 could become a widely recommended vaccine. Note, however, that it did not eliminate shingles, but rather reduced the incidence by 51%, the burden of illness and discomfort by 61% and the incidence of postherpetic neuralgia by 67%. These are very significant health benefits!

HPV vaccine highly effective

Use of the human pappilloma virus (HPV) vaccine, when approved, in adolescents before they become sexually active should be a no-brainer, but I fear politics will insert itself into this issue. Parents may be uneasy about protecting their children against what is, after all, a sexually transmitted disease (STD). That concern may be amenable to reason and calm discussion.

The “religious right” may well try to make the argument that use of this vaccine will promote promiscuity, and thus array their considerable political influence against licensure. They have, after all, together with the Roman Catholic Church, argued strongly against the use of condoms, even to prevent STDs and HIV infection. Infectious disease physicians are all too aware of this particular subversion of science by a political agenda. Witness the infamous “Plan B” emergency oral contraceptive saga.

Seasonal influenza

Finally, the seasonal influenza situation is that there is a sufficient, if not ample, vaccine supply this year, although there have been a few distribution problems. As of Dec. 1, there are a few isolates of both influenza A/H3N2 and influenza B, but no sign of a beginning epidemic.

Of great interest is the beginning debate about “mandatory” influenza vaccination of health care personnel. This appears to be coming rapidly upon us, having been promoted initially by Greg Poland, and recently endorsed by both the Association for Professionals in Infection Control and the Epidemiology and Society for Healthcare Epidemiology of America.

Will other interest groups buy into this concept? The opposition has already staked out its position, and the opposition of hospital employee union groups can probably be assumed. It will take strong support from hospital administration to bring this about. Next fall will be interesting!

The other topics merit discussion, too, but I must refer you to the accompanying stories. Happy New Year to all of you. It already promises to be eventful.