Infectious diseases in 2011: Remarkable on many fronts

Infectious Disease News notes the passing of the year, as always, by selecting Editorial Board members’ top stories from 2011. In addition, another tradition allows me, as the Chief Medical Editor, to reflect on those developments that most attracted my attention, particularly those that might resolve previous controversy or suggest important steps for future research or clinical application.

My methods are not scientific. I have not performed a careful meta-analysis, and this is not evidence-based. As always, I’d enjoy hearing the readers’ perspectives on those developments that caught their attention.

ID specialists actually treat viral infections, not just HIV

A truly remarkable explosion in new oral drugs to treat hepatitis C virus occurred in 2011. Two drugs — boceprevir (Victrelis, Schering) and telaprevir (Incivek, Vertex Pharmaceuticals) — were approved by the FDA, and many more are in development. Presentations at international meetings have shown — in small and preliminary trials — response rates approaching 100% across the HCV genotypes, and optimism is growing that short courses — perhaps 12 weeks of multi-agent combinations of oral drugs without interferon or ribavirin, attacking different points in the replicative cycle —may allow cures in most patients.

HCV is a global scourge, and many millions might be able to avert the serious liver disease, cirrhosis and hepatocellular cancer that they otherwise face if these breakthroughs actually are proven in large-scale studies. Our gastrointestinal colleagues will continue to be deeply involved in patients with more advanced disease, but ID physicians should easily apply their knowledge of HIV combination therapy in an even larger epidemic and efforts to spread this message and provide appropriate training accelerated in the past year.

Watch what you eat, again

It’s clearly not news to know that foods can be a vector for infectious diseases, but 2011 saw this reinforced in several dramatic instances. A German Shiga toxin-producing Escherichia coli strain representing an unusual combination of two others was spread in sprouts and caused a frighteningly high mortality rate from hemolytic uremic syndrome. In the United States, contaminated ground turkey was the cause of a major Salmonella Heidelberg outbreak affecting 31 states.

In August, a deadly outbreak of listeriosis was linked to contaminated cantaloupes from Colorado. Each of these outbreaks are unique, but together they underscore the growing need for closer regulation of food production and distribution along with the ever real potential for recombination and resistant organisms making a bad situation even more threatening.

Vaccinations remain hot political potato

Outbreaks of measles in Europe and mumps in the United States were linked in part to the growing reluctance of some parents to have their children vaccinated. Driven by — in my opinion — misguided and ill-informed “experts” suggesting that vaccines are dangerous and a cause of autism or other conditions, many forgo the protection of childhood vaccination, allowing the resurgence of previously well-controlled childhood infections.

The quadrivalent human papillomavirus vaccine (Gardasil, Merck) was approved in 2011 for boys, as well as girls, and this may have been the vaccine story of the year when the motives for a state-wide vaccine program for girls in Texas were questioned and when another political figure seemed to accept the possibility of vaccine as the cause of mental retardation — perhaps the nadir of informed discourse on a fundamentally important pillar of public health.

HIV prevention turned on its head, maybe

The past year saw truly notable developments at the interface of HIV treatment and prevention. As we discussed in a recent Infectious Disease News editorial, a clinical trial showed protection of women from vaginal HIV exposure with a gel of an antiretroviral drug — tenofovir — applied before and after sexual intercourse, and a major study announced at the end of 2010 showed that oral administration of tenofovir with a second drug — emtricitabine — reduced HIV acquisition in a large cohort of men who have sex with men.

Although an exciting year, 2011 also added some questions when other trials of antiretroviral-based prevention were unsuccessful. Studies of vaginal microbicides and oral pre-exposure prophylaxis (PrEP) were somewhat different in design and conducted in different populations, but we are eager to see further results this coming year to know more definitively how these prevention strategies might actually be deployed.

This past year, we also saw the dramatic proof that HIV treatment decreased transmission. The HPTN 052 trial, also well covered in Infectious Disease News, found a striking reduction — at least 96% — of HIV infection in heterosexual partners of HIV-infected people, if the infected partner initiated trial enrollment on potent combination antiretroviral therapy.

This extremely important result, coupled with a continuing and growing recognition of HIV-induced organ damage, is moving more to call for universal treatment of all HIV-infected people, regardless of disease stage as measured by CD4 cell counts. We await revisions of treatment guidelines to see how they accommodate these new developments.

Finally, another infection with political impact

Just in time for this year-end summary comes a challenging issue. US investigators, along with the Netherlands and NIH support, genetically modified a strain of avian influenza to see whether transmission could be enhanced. In an animal model in ferrets, researchers were able to substantially facilitate direct animal-to-animal transmission — so much so that concerns were raised that this could be a means of “weaponizing” aggressive human influenza viruses, and security authorities blocked publication of the manuscript describing the work. This is not the first time that infections are seen as terrorist threats, but let’s hope that research doesn’t get too focused on those questions when we have so many needs for better treatment of the patients we already serve.

All in all, an event-filled year. Let’s hope the next year begins and ends with real progress.

Paul A. Volberding, MD, is chief of medical service at San Francisco Veterans Affairs Medical Center; professor and vice-chair of the department of medicine and co-director of the Center for AIDS Research at the University of California San Francisco and is the Chief Medical Editor of Infectious Disease News. Disclosure: Dr. Volberding is an adviser to BMS and on data and safety monitoring boards for Gilead, TaiMed and the NIH.

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