Infectious Disease News: The 20th anniversary

January 2007

This writer was blissfully unaware, until the publication staff pointed it out to me, that this will be the 20th anniversary year of publication of Infectious Disease News. I would have been quite willing to let this anniversary pass without editorial comment – probably a sign of advancing age – but the timeline that appears in this issue convinced me that, just as the end-of-year editorial comments that appear each December, this anniversary offered the opportunity for a much longer view of the past 20 years.

In constructing the timeline, no attempt was made to be exhaustive in unearthing major events in infectious disease.

I suspect that each of us who lived through those years can think of something significant that could well have been included. Rather, the list serves to remind us of some of the events that happened each year, and creates a setting in which we may recall other concurrent or related events.

Early years

Our first year of publication, 1988, was in an era early in the development of antiretroviral drugs; zidovudine and several others were already on the market. This was a time early in our acquisition of knowledge about HIV transmission, and there was some reluctance by physicians, dentists, and other health care providers to provide care for patients with AIDS. This was an era in which serious calls were heard in the political arena to ship all patients with AIDS off to some remote island.

The well-remembered HIV-positive dentist in Florida, Dr. David Acer, brought concerns of transmission between patients and health care providers to a sharp focus in 1990 when a number of patients in his dental practice were infected with HIV, presumably in his office. Who can forget the image of one of his patients, young Kimberly Bergalis, being wheeled into the United States Congress pleading, along with her family, for laws to prevent such transmission of the HIV virus? This led to the 1991 CDC recommendations for preventing transmission of bloodborne pathogens in health care facilities, which, I believe, remain officially in place today.

Knowing a great deal more about HIV transmission risks today than we knew in the early 1990s, however, many of the more stringent recommendations made then are largely ignored in many hospitals today and seem strangely out of touch with contemporary practice. We are fortunate that provider-to-patient transmission of HIV has proven to be an exceedingly rare event. There is to this day no genuine understanding of precisely what happened in Dr. Acer’s dental office.

Advancements

In the mid-1990s the development of protease inhibitors and the advent of HAART brought us closer to the contemporary era in AIDS care. The very important work of the Bill and Melinda Gates Foundation and the initiation of the Global Fund to Fight AIDS, Tuberculosis and Malaria must not be overlooked. The magnitude of the challenge ahead was reinforced in 2004 when global estimates of HIV-positive individuals began to reach 40 million or more.

One very recent important event has been the CDC recommendation to make HIV screening a standard practice in medical care, doing away with the need for individual consent. Though widely acclaimed as a laudable change, it may not be as easy to implement as I once thought. Many states have laws in place that require individual informed consent, my own state included. Many states will likely revoke or revise their laws to conform to the CDC recommendations willingly, but a number of states, such as New York, are showing considerable resistance.

Vaccines

Enormous progress has been achieved in vaccines over the last two decades. Although pneumococcal vaccine has not undergone any fundamental change in its pure polysaccharide nature, a series of ACIP recommendations since its introduction have grown steadily stronger. This vaccine is universally recommended for adults aged 65 years or older in this country, with increasing calls for consideration of this vaccine at age 50. The evidence for efficacy is not unassailable, however, and one must admit that the vaccine is probably ineffective in those high-risk people one might most wish to protect. This vaccine did not pass muster when subject to the very stringent efficacy criteria of the Cochrane Collaboration. One hopes that a protein-conjugated vaccine, comparable to that used in children, will eventually become available for use in adults.

Hepatitis B, hepatitis A, varicella, rotavirus diarrhea, human papillomavirus, pertussis and invasive pneumococcal disease in children are all vaccine-preventable diseases today. I may even have forgotten one or two more.

Avian influenza

The first human cases of avian influenza (H5N1) occurred in Hong Kong in 1997. Public health officials there took the unprecedented step of culling all poultry on the island, probably several hundred thousand birds. Many of us thought that was an overreaction, but it surely was effective! We probably don’t understand to this day what that step may have done to the natural history of avian influenza.

Nonetheless, in the last four years, we have witnessed the extraordinary spread of avian influenza viruses throughout Southeast Asia, China, Russia and the former Soviet States, the Middle East, parts of Africa and Europe.

Bitter arguments still rage about the relative roles played by legal and illegal trans-shipment of poultry, and by migratory wild birds. It seems likely that all three have played a role, the relative importance of each depending on the locale and prevailing patterns of commerce.

One of the most unusual infectious disease events ever recorded occurred in 2003 – the emergence and spread of SARS. In a major scientific tour-de-force, the genomic structure of the SARS coronavirus was constructed in very short order, and preparations began for vaccine development.

Lacking any effective antiviral drug, control of the disease was entirely dependent on public health and infection control and prevention techniques. To everyone’s happy surprise, it worked! There was a huge price to pay, however, and many health care providers and scientists paid with their lives. Will SARS re-emerge at some time in the future?

In an even greater scientific triumph, a live and virulent 1918 influenza virus was literally “created” in 2004-2005, thanks to the groundbreaking (no pun intended) work of Taubenberger and many collaborators at the Armed Forces Institute of Pathology, NIAID and CDC. Some questioned the wisdom of recreating such a vicious virus, but it is already teaching us some of what made the virus so terrible, and will continue to do so.

Disappointments

It’s worth noting some “false starts”; findings that seemed promising initially, but could not be confirmed. Among these are Staphvax, an antistaphylococcal vaccine that seemed initially quite promising in preventing staphylococcal infection in hemodialysis patients. This could not be confirmed in a larger trial; however, we may not have heard the last word about this vaccine. Similarly, a promising potential etiologic link of a specific coronavirus infection to Kawasaki Disease could not be confirmed in another study.

Finally, we should note a few things that have NOT happened. An effective therapeutic and prophylactic AIDS vaccine is surely the first of these. It will still happen, eventually, but simply not yet, even though it is almost 25 years after then Secretary of Health, Education and Welfare Margaret Heckler pronounced, shortly after the discovery of the human immunodeficiency virus, that “we will have a vaccine a year from now!”

Pandemic influenza has also not happened – YET. Make no mistake, it will happen – sometime. Perhaps the sheer volume of words written about pandemic flu preparedness has managed to keep it at bay.

Finally, and thankfully, a bioterrorist attack has not happened since the anthrax mailings of 2001, a continuing mystery.

It would be difficult to imagine a more eventful 20-year period, but it’s doubtless that the next 20 years will be just as eventful, if not more so.