After 22 years, goodbye

Editor’s Note:

After 22 years and more than 250 editorials, the December 2009 issue will mark the completion of Philip Brunell’s tenure as the first and only Chief Medical Editor in the history of Infectious Diseases in Children.

Infectious Diseases in Children was created in the mid-1980s because our research showed that infectious disease topics were consistently rated highest-interest by pediatricians. A search for a Chief Medical Editor led quickly to Dr. Brunell, and quickly after launch, we knew we’d found the right man.

Dr. Brunell’s editorials resonated. Provocative, challenging and insightful, Dr. Brunell early on captured an audience and Infectious Diseases in Children earned a faithful following.

Although his editorials may be the most visible part of his role as Editor, it has been Dr. Brunell’s behind-the-scenes guidance that played an even greater role in the publication’s success. He assembled an all-star editorial board and carefully crafted our editorial coverage to bring expert-level ID information and research to our audience of office and hospital-based practitioners. He has been forever mindful of the need to extract from research what is useful to the practitioner and forever reminding practitioners to respect and rely on the science available.

And you responded. Under Dr. Brunell’s leadership, this newspaper is today the most widely read publication among pediatricians and pediatric nurse practitioners. PediatricSupersite.com, the online home of IDC, will attract more than 300,000 visits this year.

Those of us associated with the publication who have gotten to know and work with Dr. Brunell through the years are grateful not just for his leadership but for his friendship. For Dr. Brunell in person is the same man you read in print; interested and interesting, demanding and supportive, thoughtful and caring. It is truly our privilege to have shared these years with Dr. Brunell. – John C. Carter, Chief Operating Officer, Wyanoke Group

It is hard for me to believe that I have been the Chief Medical Editor for Infectious Diseases in Children for 22 years, but it is true.

At that time, Marie Rosenthal and I started this newspaper, and it has been coming to you ever since.

At its inception, I had just come off four years as chair of the Red Book marked by constant confrontation by parents’ groups opposed to immunization, and diphtheria, tetanus and pertussis in particular. They had objected, and rightly so, to the reactions to the whole cell vaccine. Unfortunately, they extrapolated from these reports to the conclusion that this vaccine caused permanent brain damage. Because of the number and size of lawsuits, American manufacturers were hesitant to enter pertussis vaccine business and many left vaccines entirely. Fortunately, several Japanese vaccine manufacturers had developed acellular pertussis vaccines, which were soon adapted to the United States after expensive and long clinical trials.

Out of this morass came legislation to vitiate the need for expensive and acrimonious legal proceedings, which had been the mechanism to adjudicate vaccine injury allegations. In its place was the National Childhood Vaccine Injury Act (NCVIA) of 1986. In addition, we put in place programs such as the Vaccine Adverse Event Reporting System. Equally important was the establishment of coordinating and planning groups to oversee our entire vaccine program.

Toward the end of that decade, we were to witness the largest measles outbreak in the United States in decades. It started along the border with Mexico and spread quickly, resulting in more than 100 deaths and 50,000 cases. The cases included poorly immunized infants in the inner cities and schoolchildren who had received only a single dose of vaccine. Subsequently, a second dose was recommended.

Earlier in that decade, we learned of a new acquired immunodeficiency disease. I saw my first case early in that decade while making rounds. I stopped to question the mother of this poorly nourished infant who had thrush and large liver and spleens and prominent lymph nodes. When she answered me in French, I had the diagnosis. Most of the cases of HIV at that time were linked to Haiti. There was little to offer these patients until the first drug AZT, with many more to follow. One of the most important things we learned is that non-sexual person-to-person contact was not going to spread the disease. Without this information, we would have had a sorry society. Subsequently, the virus was isolated and the frustrating quest for a vaccine begun.

One of the most exciting developments of that decade was the development of the first polysaccharide Haemophilus vaccines. The initial vaccines to be licensed were approved for children 18 months of age or older because younger children did not respond to polysaccharide vaccines. Shortly after this, conjugate vaccines appeared and with these vaccines, meningitis virtually disappeared. We went from 20,000 invasive cases of Hib disease annually to slightly more than 100 at the current time. The conjugate pneumococcal vaccines were soon to follow. This development continues to have a profound impact.

Were there non-vaccine issues? Certainly! We redefined otitis media, casting doubt on some of the findings published prior to this time. We found that not all otitis media was to be managed in the same manner and that many did not require antimicrobials.

Antibiotic resistance continues to plague us. Pneumococcus resistance had been a growing problem. Staphlococcus has returned to plague us. Methicillin, which had rescued us from the staph epidemic of the ‘60s, has become useless in many situations.

At long last we had antiviral drugs, only to see strains of influenza virus that were resistant to the amantadines or to the neuraminadase inhibitors. This is particularly troubling with the advent of the current novel influenza pandemic strain of the virus.

We still wonder about the cause of Kawasaki syndrome, but we have learned that because of the cytokine storm accompanying the disease, anti-TNF inhibitors can be added to our treatment armamentarium. It also has become obvious that the original CDC epidemiologic criteria for counting cases would miss some of the cases of incomplete Kawasakis. Algorithms were developed to proceed in the absence of the original criteria.

Many years ago, while a young professor at NYU, our dean, Saul Faber told the graduating class that "you no longer are medical students, you now are students of medicine." Thank you to all my classmates.