The top 10 news stories for 2006

December 2006

As has been a long-standing tradition for more than a decade, December offers the opportunity to look back at the year and weigh which of the stories that appeared in Infectious Disease News seemed most important, both in terms of scientific interest, and in infectious disease practice. The staff put together a list of about 20 topics; these were then voted on by members of the editorial board. From this process emerged the top ten stories. We made no attempt to rank order within the top ten; so in no particular order, here they are:

• Herpes zoster vaccine recommended for adults aged 60 or older
• E. coli outbreak caused by spinach
• New HIV testing recommendations from CDC
• 100 million doses of influenza vaccine expected this year
• Changing epidemiology of C. difficile
• HPV vaccine for girls aged 11 to 12 years
• The 25th anniversary of HIV/AIDS
• Spread of avian influenza viruses across Eurasia
• Rotavirus vaccine again recommended for infants
• TDaP vaccine recommended for adolescents and adults

A few general observations can be made. First, it was obviously a big year for vaccines, especially those recommended for adolescents and adults. Second, influenza continues to capture both scientific and public interest. Third, the 25th anniversary of HIV/AIDS offered the opportunity to review how much has been learned and what awaits future research. Finally, some topics that had been in the running for the last for three to five years failed to make the cut this year, notably CA-MRSA, increasing antibacterial drug resistance and the need for new drug development, and “emerging” infectious diseases.

Elsewhere in this issue are updates of the top ten stories. Space will not permit comment on each of these, but a few observations on some of the broader topics are appropriate.

Vaccines

Zostavax, the new herpes zoster vaccine developed by Merck, was licensed by the FDA earlier this year. There was but a single field trial, the pivotal trial that was carried out by Mike Oxman and many colleagues, and reported several years ago in The New England Journal of Medicine. It was virtually the perfect field trial, and indeed could become a model that designers of subsequent field trials may seek to emulate. Merck has chosen to price this product quite cautiously at about $150 per dose, quite different from the earlier predictions of somewhere from $300 to $500 per dose.

One might wish that the approximate efficacy of 50% in preventing herpes zoster, and that the slightly more than 60% efficacy in reducing post-herpetic neuralgia had been higher; but recalling the natural history of varicella-zoster infection, the 50% reduction is still a very significant benefit to the target population. It is not clear at this time whether Medicare will cover this vaccine, given the financial constraints with which we are familiar. Perhaps doctors have been spoiled by the many other vaccines that yielded 85% to 95% protective efficacy figures. I will certainly take it, and recommend it to my spouse as well.

HPV vaccines are among those that have yielded very high efficacy figures in preventing infection with the HPV types included in the vaccine. Merck was out in front with Gardasil, their quadrivalent vaccine (HPV types 6/11/16/18), which was licensed this year. GlaxoSmithKline’s bivalent (HPV types 16/18) vaccine might be licensed in 2007. Although it is recommended for young women aged 13 to 26 years, the primary target group is young women aged 11 to 12, who are not yet sexually active, and therefore are unlikely to have been exposed to HPV.

This will, of course, cause concerns among some parents, and there will need to be individual decision-making within family units. There have already been many expressions of concern from the ultra-right, who seem to believe that administration of this vaccine will confer a license for promiscuity. I am not aware of any large-scale organized opposition to using this vaccine; it is, after all, difficult to argue against a vaccine that prevents cervical cancer. Recently, the state of New Hampshire agreed to provide this vaccine free of charge to resident children in need, which is an encouraging development.

The need for a soluble pertussis vaccine for adolescents and adults has been apparent for some time; the recent outbreak at Boston Children’s Hospital is yet another example. Health care personnel who do primary care, pediatrics, obstetrics, and emergency care represent a high-priority target population. Hospitals should waste no time ensuring pertussis coverage of their at-risk staff, to protect their patients and, of course, their staff.

We have written very little about rotavirus vaccines since the Wyeth RotaShield-associated cases of intussusception a number of years ago. Today there are two new products from GlaxoSmithKline and Merck that were licensed after unusually large and extensive field trials. Indeed, they were tested to a level of safety that was unprecedented in previous vaccine trials. With that level of safety assurance, the ACIP again recommended these products for universal use in U.S. infants. I recall thinking that was a pretty gutsy recommendation, given the history of the first rotavirus vaccine; but it was reassuring to appreciate the extent of the field trials.

Influenza

Influenza vaccine is in plentiful supply this year, troubled only be the seemingly inevitable short-term shortages caused by mal-distribution. Avian influenza was very much in the news last winter and spring, as the virus spread across Eurasia, the Middle East and into Africa. Activity of the H5N1 virus seemed to quiet down during the summer months, in common with “seasonal” influenza in the Northern Hemisphere, but has picked up again in the last several months.

Some exciting scientific observations are beginning to give us some appreciation of the pathogenesis of avian influenza, why it is so difficult to diagnose, and why it shows such a predilection for the lower respiratory tract.

Substantial progress is being made in vaccine development, and it should be noted that even the federal government seems to be accepting the reality that some kind of adjuvant is going to be needed in this vaccine to enable production of adequate supplies of a protective vaccine. On the down side, how much longer will the public pay attention to the threat of pandemic influenza? Is fatigue beginning to set in already?

HIV/AIDS

The 25th anniversary of HIV/AIDS has resulted in a number of reflections on the many things we have learned in those years, and what remains for the future. One such reflection, by Tony Fauci, is found in this issue of Infectious Disease News.

In my view, however, the most important HIV/AIDS story for 2006 was not the anniversary itself, but rather the new testing recommendations released by CDC. Finally being true to its public health mission, CDC now recommends that everyone aged 13 to 64 years be tested simply as part of his or her standard medical care. The goal is to identify the quarter of a million or more Americans who are HIV positive and don’t know it, and get them care and treatment. This should result in earlier care, prolonged life span, and a reduction in HIV transmission.

There have been murmurs of objection from some activist groups and the ACLU, but in general these recommendations have been warmly received. Fear of AIDS and discriminatory behavior, though they still exist, are fortunately not as prominent today as they have been.

Though I have not run out of top ten stories to comment on, I have run out of space. My wish for all of you is for Happy Holidays!