Chief medical editor reflects on 2007

December 2007

As we welcome 2008, it is important to reflect on all that happened during 2007.

The most significant and ominous happening has been the increase in methicillin-resistant Staphylococcus aureus this past year.

Although the frequency and resistance patterns vary by region, it is safe to say that everyone is experiencing an increase in MRSA cases. What is more, MRSA is appearing in newborn nurseries and in schools.

Skin infections are commonly seen in outpatient facilities and in offices. Invasive disease is mainly seen in the hospital setting. Efforts to eradicate MRSA carriage with intranasal mupirocin with or without systemic therapy have been mixed. Clindamycin is the mainstay of therapy for MRSA but it is essential to test for resistance and inducible resistance by requesting the D-test. Again, resistance varies with location. Trimethoprim-sulfamethoxazole and tetracyclines have been alternatives for ambulatory therapy.

The other concern has been the increasing prevalence of type 19A pneumococcus. Although the number of vaccine-type pneumococcal isolates has decreased markedly and invasive disease and resistance also is down, 19A looms as a potentially serious problem. This isolate has been responsible for invasive infections which have tended to be resistant. Clinical trials of vaccines with an increased number of pneumococcal serotypes continue, but 19A thus far does not seem to be one that is included in the new vaccines.

New indications for vaccines

The live-intranasal influenza vaccine (Flumist, MedImmune) and meningococcal conjugate vaccine (Menactra, MCV4, Sanofi Pasteur) have been approved for use starting as young as 24 months of age. The recommendations for routine immunization with the latter will continue to be for teens and those who are at increased risk. Intranasal flu vaccine provides an alternative to intramuscularly-administered flu vaccine. In children, the live vaccine may give longer and broader protection than the killed vaccines. It is important that children younger than age 8 receive two doses of vaccine in a single season. Having received a dose in a previous year does not count as one of the two doses. Children with asthma, for whom the vaccine is strongly recommended will still need to receive killed vaccine. It is important to remember that those in contact with infants and toddlers including parents and caretakers should be immunized to minimize spread to these youngsters. Thus far, this has been a light influenza year and there is lots of vaccine available. Remember that in recent years, February has been the peak year for influenza. Thus, immunization should be continued into the new year. Finally, all health care personnel should be immunized with influenza vaccine.

Hepatitis A vaccine now is recommended for all children starting at 12 months of age. Previously, the vaccine had been approved for those age 2 years and older. A routine two-dose schedule for varicella vaccine now is recommended and this can be achieved with the measles-mumps-rubella-varicella (MMRV, ProQuad, Merck) vaccine. Post partum immunization and two doses for adults at risk of contact with children also is recommended.

The discussion about the use of HPV vaccine is ongoing. Studies have been published indicating it prevents but does not affect the consequences of infection. Stated another way, the consequences of infection acquired during the teen years will not be affected by deferring vaccine till these young women are older.

Although we have an abundance of wonderful new vaccines, the newer ones also tend to be much more expensive. Relief for physicians who administer these vaccines continues to be discussed as the cost of stocking them in onerous.

Evidence that vaccines do not cause autism or mercury poisoning continues to accumulate and, for those who seek it, the case seems to be closed. The AAP’s statement on autism now focuses attention on detection and treatment rather than the blame game. However, there are some who will continue to believe what they will believe. Parents who refuse to have their children immunized have created a problem for physicians who care for their children as they expose those in the waiting room to vaccine-preventable diseases. How to manage these parents continues to be discussed. It is important to document and if possible get parental signature that these issues have been discussed with them. Measles spread from a Chinese adoptee this past year furnishes another reminder that vaccine-preventable diseases continue to be a threat.

Finally, a very happy holiday season to you all and to your families and my best wishes for a healthy and happy new year.