A look back at the past two decades

January 2007

Is it 20 years?

It is hard to believe that I have been doing this for two decades. But let’s reflect on the important news events during this time.

As we look back, the most important things probably are those that did not happen.

HIV, which is off the radar screen for most of us at this time, was probably the most significant news of the decades. What is apparent is what did not happen to our society as a consequence of the introduction of HIV. There was near hysteria about the spread of HIV, including among health care workers, as well as panics among those in day care centers and schools.

I recall a hospital executive board meeting at which a representative of the anesthesia department demanded to know the HIV status of patients. Whether or not they had HIV had an influence on whether he would attend that patient. At this same time, one of our patients who had HIV was asked to leave her Girl Scout troop after she revealed her diagnosis.

Fortunately, wiser heads prevailed, and now we live in a society that is not paralyzed by this phobia and where concerns about the spread of HIV are handled more rationally. To those who withstood public pressure to restrict those suspected of being infected with HIV, we owe a debt of gratitude.

One cannot discuss HIV without acknowledging the decline of vertically transmitted cases in the United States through rigorous case surveillance, including testing pregnant women and using zidovudine for prophylaxis when these women were found to have HIV. This program is now being used in many developing countries, but there still is much work to be done.

Those of us who were around prior to the advent of Haemophilus influenzae type b (Hib) vaccine can appreciate what a momentous achievement the development of conjugated capsular polysaccharide antigens has been. Not only has meningitis become uncommon, but also so have other invasive diseases caused by Hib. When was the last time you saw a case of epiglottitis, or septic arthritis caused by Hib?

With the development of conjugate vaccines against pneumococcus and meningococcus, we can look forward to bacterial meningitis in this country becoming a zebra. There is still work to be done toward developing a meningococcal B vaccine to address meningitis in infants where the incidence of meningococcal disease is greatest. Finally, we cannot forget the global challenge meningitis poses, particularly group A disease in sub-Saharan Africa.

Still waiting on antibiotics

What we have not seen a whole lot of during the past 20 years is a plethora of new antibiotics. This is problematic, especially since this lack of new antibiotics comes at the same time the rate or resistance is on the rise.

In an effort to stem the growth of resistant organisms, guidelines have been issued for diagnosis and treatment of ear infections. The criteria for diagnosis of acute otitis media have been defined. We have been urged to use pneumatic otoscopy, and health officials are stressing the importance of proper illumination. We also have been urged to wait and see in many situations, as a lot of cases of otitis media are self-limited and do not require antimicrobial therapy. We have been cautioned that otitis media with effusion, which does not require antimicrobial therapy, should be differentiated from otitis media whenever possible.

The progressive increase in the number of medications to which staphylococcus has become resistant is a continuing problem. Methicillin-resistance was first noted in hospitals, jails and nursing homes. It is a growing concern not only in hospital patients, but also in the community and in newborns. These organisms are resistant not only to methicillin, but to other agents as well. Of the few new drugs to hit the market recently, many have been directed at multiresistant staph.

In contrast to the dearth of new antibiotics, there has been a plethora of new vaccines. There also has been an emphasis on immunization of adolescents. For this age group, human papillomavirus vaccine, conjugated meningococcal vaccine and acellular pertussis combined with diphtheria and tetanus vaccines are now recommended for children aged 11 to 12 years. Also, officials with the Advisory Committee on Immunization Practices are urging pediatricians to make certain that hepatitis B vaccines are up to date in their patients and that these patients also have received their two doses of measles-mumps-rubella-vaccine (MMRV, ProQuad, Merck).

The vaccine scene has not been without problems, such as people’s continued concerns about mercury, autism and the administration of multiple vaccines at a single visit. Fears probably have been stoked by the withdrawal of the initial rotavirus vaccine due to associated intussusception and the removal of thimerosal from childhood vaccines. Our current concern is the association of Guillain-Barré Syndrome with the new meningococcal conjugate vaccine.

Not the least of the challenges ahead is the cost of new vaccines and the fear that this may result in some children not being immunized properly as pediatricians await reimbursement for these sometimes costly vaccines. We cannot be complacent about vaccine-preventable diseases, as we have already seen a large outbreak of mumps in the United States and a smaller outbreak of measles in recent years.

We have witnessed some exciting developments during the past few decades and it is fair to say things will not be dull in the future. At this time, I want to thank the contributors, the editorial board, my colleagues at SLACK, and particularly the former IDC Editor in Chief Marie Rosenthal for their support during the past two decades. And I thank the readers for their encouragement and their interest. My best wishes to all for the coming years.

*Editor’s note: For more reflection on the past 20 years, check out our timeline.

[Twenty Years in Pediatrics: A Timeline] (Adobe PDF)