Happy New Year! It's time again for my annual prognosis of the top 10 infectious disease issues likely to have an impact on our practices in the next 12 months.
▸ 1. Local school-based immunization programs could become a reality. Nationally, it will take increased vaccine production and better organization of school-based infrastructure. Still, I foresee some local initiatives coming to fruition in 2008.
We have evidence that such programs work. In a recent study, Dr. James C. King Jr. and his associates at the University of Maryland, Baltimore, identified 11 demographically similar clusters of elementary schools (24 total) in four states. One school in each cluster served as the “intervention” school, and the others as controls. Healthy children aged 5 years and older in the intervention schools were offered free nasal influenza vaccine before the 2004–2005 influenza season (N. Engl. J. Med. 2006;355:2523–32).
The investigators identified the predicted peak weeks of influenza activity for each state, then evaluated rates of illness and school absence in the respective schools by a survey of parents immediately following the predicted week of peak influenza activity. Of the 5,840 children in the intervention schools, 47% (2,717) received the vaccine.
Compared with the children in the control schools, those in vaccinated schools were significantly less likely to experience any fever or flulike illness (40% vs. 52%) or to visit a clinic or physician's office for any type of care (7 vs. 11 per 100 patients). They also received fewer prescriptions, used fewer over-the-counter medicines, and were less likely to miss school.
While we're waiting for school programs, remember that it's still not too late to have an impact personally on influenza disease by targeting your high-risk patients and offering vaccine to any child in your practice.
▸ 2. Community pneumonia and otitis media may become harder to treat as pneumococcal disease rates plateau and new strains continue to appear. Serotype 19A will emerge as the nemesis and cause more disease associated with multidrug resistance. In the PROTEKT US study, coverage with the 7-valent conjugate pneumococcal vaccine (PCV7) and antimicrobial susceptibility among Streptococcus pneumoniae isolates collected from children aged 0–14 years were examined for the periods 2000–2001, 2002–2003, and 2003–2004. The most common serotypes in year 4 were the nonvaccine serotypes 19A (19% of all isolates), 6A (8%), 3 (8%), 15 (6%), and 35B (6%), along with 19F (13%), which is included in the vaccine (J. Clin. Microbiol. 2007;45:290–3).
Although the proportion of S. pneumoniae isolates from the U.S. pediatric population covered by PCV7 decreased substantially in the 4 years after the vaccine was introduced, there were significant increases in strains that were resistant to commonly used antibiotics, including beta-lactams and macrolides, as well as in multidrug resistant strains, particularly among respiratory tract isolates.
In a separate report, Dr. Michael E. Pichichero and Dr. Janet R. Casey identified serotype 19A pneumococcus as an otopathogen that is resistant to all antibiotics currently approved for the treatment of acute otitis media in children (JAMA 2007;298:1772–8). Will pediatricians need to be trained in tympanocentesis again? My crystal ball says maybe.
▸ 3. Travel-related issues will arise more often in your practice. The number of children traveling overseas continues to increase. While curbside consultations generally target malaria prophylaxis, pediatricians also should offer counseling regarding food- and waterborne disease, other vector-borne diseases, and airborne diseases.
Such counseling should take into account the patient's age, nutritional status, and any underlying illness. All routine immunizations should be updated. The country, accommodations, and length of trip will all dictate which travel vaccines the child will need. Other topics to cover include food and water precautions, planning for symptomatic treatment of traveler's diarrhea, protection against mosquito-borne pathogens and TB where it is endemic, and a plan for evaluation on return for those staying longer than a month. I particularly recommend an article entitled, “Germs on a plane—infectious issues and the pediatric international traveler: What pediatricians should know,” by two Canadian researchers (Pediatr. Ann. 2007;36:344–51).
▸ 4. A new blood test for tuberculosis may supplant intradermal skin testing. Interferon-γ release assays using whole blood may reliably determine if a child has been infected with TB. The tests require just one visit and the results are often available within 1 day. The tests provide greater specificity than tests using purified protein derivatives such as the TB antigen, with similar sensitivity.
▸ 5. The vaccine reimbursement issue will continue to dominate discussions among policy experts, but it's not likely we'll see a solution. In February 2007, the American Academy of Pediatrics and the American Medical Association held a joint congress at which major proposals included setting national standards for minimal reimbursement, standardizing vaccine administration fees, and having vaccine manufacturers work with pediatricians to offset the cost for inventory of new vaccines. It's a start. I hope that working through bureaucratic channels won't take as long as I anticipate.