Looking Ahead in Infectious Disease

Yogi Berra once said, “It's tough to make predictions, particularly about the future.” With that said, here are my top predictions for pediatric infectious disease developments in 2005:

▸ Changes in the U.S. vaccine development infrastructure will allow for the distribution of 125 million doses of trivalent inactivated influenza vaccine for the 2005-2006 season. But despite the increase in demand for vaccine fostered by the 2004-2005 shortage, a relatively mild influenza season this winter will lead to relative apathy next season, and 25 million of the 125 million doses manufactured doses will not be utilized.

▸ A vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) will be licensed and implemented for use in the 11- to 13-year-old population, probably by June 2005. Although pertussis cases will decrease from the peak year of 2004 (partly as a reflection of the normal 2- to 3-year cycle of infection), mortality from pertussis in those younger than 4 months of age will not decrease during 2005.

At our pediatric center, we had a 300% increase in confirmed pertussis cases in 2004, compared with the average annual number of cases seen over the last 30 years. And in contrast to past years where diagnoses were made mostly in infants who required hospitalization, many of last year's cases have been linked to school outbreaks.

▸ Methicillin-resistant Staphylococcus aureus (MRSA) infection in the healthy child will reach epidemic numbers. (One pediatrician in our area who has been in practice for over 30 years says he has never seen so many children with boils!) The importance of draining abscesses will once again be brought to light, and novel antibiotic regimens will be utilized more commonly by the pediatric practitioner.

▸ World AIDS day was observed Dec. 1 and brought to attention the enormous global impact of this infection, particularly focusing on the impact in women. Early in the epidemic, men outnumbered women among HIV-infected individuals, but current figures show more than 50% of adults living with HIV/AIDS in the United States are women, with heterosexual intercourse being the major vector of transmission.

Data from the Centers for Disease Control and Prevention show that HIV infection rates have more than tripled among American teens and adult women since 1986. New cases will continue to occur and minority teenagers will be the hardest group to identify and treat.

▸ A diagnostic test for Kawasaki disease is close, thanks to Anne Rowley, M.D., of Northwestern University, Chicago, but will not be available for 2 more years.

▸ Vancomycin-resistant enterococcal (VRE) colonization in the hospitalized high-risk pediatric patient will become increasingly important and will challenge many more children's hospitals to provide special VRE wards.

▸ Rates of invasive pneumococcal infection in children will plateau as new serogroups of pneumococcus emerge, but cases of meningitis and empyema will continue to occur.

▸ Reports of breakthrough varicella will continue to be reported, while a second dose of varicella vaccine will be recommended by the end of 2005.

▸ The ambitious goal of the World Health Assembly to interrupt wild polio transmission globally by early 2005 will be difficult to achieve. The WHA notes that success depends on “sufficient political will, oversight, and accountability.” Accessing all children, particularly those who live in areas of armed conflict, remains the greatest challenge.

While the number of polio cases worldwide has decreased from 350,000 in 1988 to fewer than 800 cases in 2003, six countries globally are still polio endemic: Nigeria, India, Pakistan, Niger, Afghanistan, and Egypt.

▸ The scariest prediction of all: Human avian influenza cases will emerge beyond the borders of Asia. All known subtypes of influenza A circulate among wild birds. While most demonstrate low pathogenicity, mutation to highly lethal forms has occurred. Strains have jumped the species barrier, resulting in human avian influenza cases which have now been confirmed in Hong Kong, Vietnam, and Thailand, with case fatality rates of up to 70%.

Now, experts fear that reassortment between human and avian subtypes could generate viruses of pandemic potential. Would antiviral therapy be beneficial? (These viruses are typically resistant to amantadine and rimantadine but susceptible to oseltamivir and zanamivir.) Do newer classes of antivirals such as short-interfering RNAs (siRNAs) hold promise for prevention and treatment of influenza A infection? Will the vaccine technology known as “reverse genetics,” which allows the generation of an influenza virus entirely from cloned cDNAs, provide a tool for more efficient vaccine production and development? We can hope, but on this one I'd rather not try to predict.

Yogi Berra once said, “It's tough to make predictions, particularly about the future.” With that said, here are my top predictions for pediatric infectious disease developments in 2005:

▸ Changes in the U.S. vaccine development infrastructure will allow for the distribution of 125 million doses of trivalent inactivated influenza vaccine for the 2005-2006 season. But despite the increase in demand for vaccine fostered by the 2004-2005 shortage, a relatively mild influenza season this winter will lead to relative apathy next season, and 25 million of the 125 million doses manufactured doses will not be utilized.

▸ A vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) will be licensed and implemented for use in the 11- to 13-year-old population, probably by June 2005. Although pertussis cases will decrease from the peak year of 2004 (partly as a reflection of the normal 2- to 3-year cycle of infection), mortality from pertussis in those younger than 4 months of age will not decrease during 2005.

At our pediatric center, we had a 300% increase in confirmed pertussis cases in 2004, compared with the average annual number of cases seen over the last 30 years. And in contrast to past years where diagnoses were made mostly in infants who required hospitalization, many of last year's cases have been linked to school outbreaks.

▸ Methicillin-resistant Staphylococcus aureus (MRSA) infection in the healthy child will reach epidemic numbers. (One pediatrician in our area who has been in practice for over 30 years says he has never seen so many children with boils!) The importance of draining abscesses will once again be brought to light, and novel antibiotic regimens will be utilized more commonly by the pediatric practitioner.

▸ World AIDS day was observed Dec. 1 and brought to attention the enormous global impact of this infection, particularly focusing on the impact in women. Early in the epidemic, men outnumbered women among HIV-infected individuals, but current figures show more than 50% of adults living with HIV/AIDS in the United States are women, with heterosexual intercourse being the major vector of transmission.

Data from the Centers for Disease Control and Prevention show that HIV infection rates have more than tripled among American teens and adult women since 1986. New cases will continue to occur and minority teenagers will be the hardest group to identify and treat.

▸ A diagnostic test for Kawasaki disease is close, thanks to Anne Rowley, M.D., of Northwestern University, Chicago, but will not be available for 2 more years.

▸ Vancomycin-resistant enterococcal (VRE) colonization in the hospitalized high-risk pediatric patient will become increasingly important and will challenge many more children's hospitals to provide special VRE wards.

▸ Rates of invasive pneumococcal infection in children will plateau as new serogroups of pneumococcus emerge, but cases of meningitis and empyema will continue to occur.

▸ Reports of breakthrough varicella will continue to be reported, while a second dose of varicella vaccine will be recommended by the end of 2005.

▸ The ambitious goal of the World Health Assembly to interrupt wild polio transmission globally by early 2005 will be difficult to achieve. The WHA notes that success depends on “sufficient political will, oversight, and accountability.” Accessing all children, particularly those who live in areas of armed conflict, remains the greatest challenge.

While the number of polio cases worldwide has decreased from 350,000 in 1988 to fewer than 800 cases in 2003, six countries globally are still polio endemic: Nigeria, India, Pakistan, Niger, Afghanistan, and Egypt.

▸ The scariest prediction of all: Human avian influenza cases will emerge beyond the borders of Asia. All known subtypes of influenza A circulate among wild birds. While most demonstrate low pathogenicity, mutation to highly lethal forms has occurred. Strains have jumped the species barrier, resulting in human avian influenza cases which have now been confirmed in Hong Kong, Vietnam, and Thailand, with case fatality rates of up to 70%.

Now, experts fear that reassortment between human and avian subtypes could generate viruses of pandemic potential. Would antiviral therapy be beneficial? (These viruses are typically resistant to amantadine and rimantadine but susceptible to oseltamivir and zanamivir.) Do newer classes of antivirals such as short-interfering RNAs (siRNAs) hold promise for prevention and treatment of influenza A infection? Will the vaccine technology known as “reverse genetics,” which allows the generation of an influenza virus entirely from cloned cDNAs, provide a tool for more efficient vaccine production and development? We can hope, but on this one I'd rather not try to predict.

Yogi Berra once said, “It's tough to make predictions, particularly about the future.” With that said, here are my top predictions for pediatric infectious disease developments in 2005:

▸ Changes in the U.S. vaccine development infrastructure will allow for the distribution of 125 million doses of trivalent inactivated influenza vaccine for the 2005-2006 season. But despite the increase in demand for vaccine fostered by the 2004-2005 shortage, a relatively mild influenza season this winter will lead to relative apathy next season, and 25 million of the 125 million doses manufactured doses will not be utilized.

▸ A vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) will be licensed and implemented for use in the 11- to 13-year-old population, probably by June 2005. Although pertussis cases will decrease from the peak year of 2004 (partly as a reflection of the normal 2- to 3-year cycle of infection), mortality from pertussis in those younger than 4 months of age will not decrease during 2005.

At our pediatric center, we had a 300% increase in confirmed pertussis cases in 2004, compared with the average annual number of cases seen over the last 30 years. And in contrast to past years where diagnoses were made mostly in infants who required hospitalization, many of last year's cases have been linked to school outbreaks.

▸ Methicillin-resistant Staphylococcus aureus (MRSA) infection in the healthy child will reach epidemic numbers. (One pediatrician in our area who has been in practice for over 30 years says he has never seen so many children with boils!) The importance of draining abscesses will once again be brought to light, and novel antibiotic regimens will be utilized more commonly by the pediatric practitioner.

▸ World AIDS day was observed Dec. 1 and brought to attention the enormous global impact of this infection, particularly focusing on the impact in women. Early in the epidemic, men outnumbered women among HIV-infected individuals, but current figures show more than 50% of adults living with HIV/AIDS in the United States are women, with heterosexual intercourse being the major vector of transmission.

Data from the Centers for Disease Control and Prevention show that HIV infection rates have more than tripled among American teens and adult women since 1986. New cases will continue to occur and minority teenagers will be the hardest group to identify and treat.

▸ A diagnostic test for Kawasaki disease is close, thanks to Anne Rowley, M.D., of Northwestern University, Chicago, but will not be available for 2 more years.

▸ Vancomycin-resistant enterococcal (VRE) colonization in the hospitalized high-risk pediatric patient will become increasingly important and will challenge many more children's hospitals to provide special VRE wards.

▸ Rates of invasive pneumococcal infection in children will plateau as new serogroups of pneumococcus emerge, but cases of meningitis and empyema will continue to occur.

▸ Reports of breakthrough varicella will continue to be reported, while a second dose of varicella vaccine will be recommended by the end of 2005.

▸ The ambitious goal of the World Health Assembly to interrupt wild polio transmission globally by early 2005 will be difficult to achieve. The WHA notes that success depends on “sufficient political will, oversight, and accountability.” Accessing all children, particularly those who live in areas of armed conflict, remains the greatest challenge.

While the number of polio cases worldwide has decreased from 350,000 in 1988 to fewer than 800 cases in 2003, six countries globally are still polio endemic: Nigeria, India, Pakistan, Niger, Afghanistan, and Egypt.

▸ The scariest prediction of all: Human avian influenza cases will emerge beyond the borders of Asia. All known subtypes of influenza A circulate among wild birds. While most demonstrate low pathogenicity, mutation to highly lethal forms has occurred. Strains have jumped the species barrier, resulting in human avian influenza cases which have now been confirmed in Hong Kong, Vietnam, and Thailand, with case fatality rates of up to 70%.

Now, experts fear that reassortment between human and avian subtypes could generate viruses of pandemic potential. Would antiviral therapy be beneficial? (These viruses are typically resistant to amantadine and rimantadine but susceptible to oseltamivir and zanamivir.) Do newer classes of antivirals such as short-interfering RNAs (siRNAs) hold promise for prevention and treatment of influenza A infection? Will the vaccine technology known as “reverse genetics,” which allows the generation of an influenza virus entirely from cloned cDNAs, provide a tool for more efficient vaccine production and development? We can hope, but on this one I'd rather not try to predict.