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As 2008 ends, there are reasons for optimism in the new year
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It’s hard to escape that the biggest stories of the year did not appear in Infectious Diseases in Children but they certainly will affect what appears in our pages for some time to come.
I speak of course of the election of our new president, which was an upper, and the economy, which is a downer. I was on a plane to London when I heard the election results on NBC and was both relieved and euphoric. This election cannot help but affect the health care of children and both the practice and the research environment. Unfortunately, these may be delayed until the economic ship can be righted. But I cannot help but be optimistic that we will be embarking on a new course.
What else happened in 2008? One of the problems that is entwined in our political economic system is the cost of stocking vaccines in our offices and seeing that children do not go unimmunized. I learned in the United Kingdom that there is a resurgence of measles and at least one death has been reported. With a population one-fifth of ours, the U.K. already has about six times as many cases as we do in, what is for us, a bad measles year. Their problem is not financing immunization but maintaining public confidence, a problem with which we are familiar. This is and will continue to be a major issue for us in the foreseeable future. There is a major effort to organize us for this. The front line will be our offices, where we must be prepared with accurate information about the risks and benefits of vaccines.
We had seen some changes in both recommendations for and in the vaccines we use. There has been some resistance to the introduction of human papillomavirus vaccine, the opposition, in some cases, from groups who believe it will increase promiscuity. The rotavirus vaccines have already had a major effect on morbidity from diarrhea and there is encouraging information from Canada on the success of their campaign to immunize adolescents with the tetanus-diphtheria-acellular-pertussis vaccine. The uptake of adolescent vaccines in the United States has been OK but not robust.
One of the problems we have encountered has been in vaccine supply. Haemophilus influenzae type b vaccination has had to be curtailed, and there has been a scarcity of varicella vaccine, which has affected the supply of the measles-mumps-rubella-varicella vaccine. It also has been observed that fever and febrile convulsions have been more frequent, nine vs. four/10,000, with the combination that has led to the revision of the preference for the combination to a statement that we can use either. During the year, we also have had some new combinations of the infant vaccines hit the market.
Probably the major changes in our immunization recommendations has been to immunize all children over the age of 6 months against influenza and the observation that immunization of pregnant women during pregnancy will reduce the risk of influenza in their infants. We have become increasingly aware of the morbidity in infants and children from the influenza A surveillance system that is now in place to track influenza deaths in the pediatric age group. The amantadines are of little use in treating influenza, and there has been some increase in resistance of neurominadase inhibitors to influenza A isolates. One of the great disappointments of 2008 was the mismatch between the strains in the vaccine and those that actually circulated. This has led to poor efficacy of the 2008 influenza vaccines. The one for the current season will be revised to contain strains that are believed will be prevalent in the coming year.
We have seen some influenza complicated by staphyloccus producing severe pneumonia in children. Methicillin resistant Staphylococcus aureus continues to increase in frequency with some increases in resistance to clindamycin in certain communities. It has been recommended that when this exceeds 10%, then alternatives should be considered for initial outpatient treatment. MRSA continues to be a major problem in health care facilities.
The enthusiasm for the seven-valent pneumococcal conjugate vaccine has been somewhat tempered by the growing numbers of cases of severe pneumococcal disease, eg, otitis, empyema and mastoiditis that have been found to be caused by strains not contained in this preparation, particularly 19A. Many are resistant to the antimicrobials we have successfully used in the past to treat pneumococcus. However, we have learned that clinical trials of new conjugate vaccines containing 13 strains of pneumococcus are well under way.
Despite some of the gloom that now prevails, we have much to look forward to in the New Year. May it be a healthy and happy one for you and your families!