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doi:10.1111/jpc.12795
REVIEW ARTICLE
Paediatric infectious diseases: The last 50 years Mike Starr Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia
Abstract: Many advances and challenges have occurred in the field of paediatric infectious diseases during the past 50 years. It is impossible to cover all of these in a short review, but a few highlights and lowlights will be covered. These include virtual disappearance of some infectious diseases, emergence of new ones, infections in the immunocompromised, antimicrobial resistance, development of new and improved antimicrobials, improved diagnostic tests and the Human Microbiome Project. Key words:
infectious diseases; HIV; microbiome.
Dating back to the 1st century CE, infections have been major causes of childhood morbidity and mortality, as they still are in the developing world.1 However, the discipline of paediatric infectious diseases was not recognised as a separate entity until the 1960s. Since then, the subspecialty has become more clearly defined and differentiated from the rest of paediatrics. In the first volume of the Australian Paediatric Journal in 1965, there were only three papers relating to infectious diseases, two of which dealt with tuberculosis (TB). A Case of Congenital Tuberculosis with Unusual Features describes the case of a 6-week-old baby who died of what was diagnosed at autopsy as TB.2 The mother, who already had seven children, was subsequently found to have tuberculous endometritis. Other members of the family were screened but did not have evidence of TB, at which point, ‘the mother admitted that this child was not by her husband’. The father was identified, and it was discovered that 2 months before the birth of the child, he had been treated for tuberculous epididymitis and pulmonary TB. The other two articles in 1965 were not quite as indelicate.3,4 In the last few months, the Journal of Paediatrics and Child Health has published over 20 articles relating to infections in children. It is impossible to cover all of the issues and advances in the field in a short review, but here are a few of the highlights and lowlights: • Virtual disappearance of some infectious diseases • Emergence/recognition of new infectious diseases (and re-emergence of old ones) • Global infectious disease epidemics • Infections in the immunocompromised • Emergence of antimicrobial resistance • Development of new and improved antimicrobials Correspondence: Dr Mike Starr, Department of General Medicine, Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Fax: 9345 4751; email: [email protected] Conflict of interest: The author has no conflicts of interest. Accepted for publication 8 October 2014.
12
• Improved diagnostic tests • The Human Microbiome Project A reduction in the global burden of infectious diseases has been a result of a number of factors including improvements in sanitation and hygiene, the discovery of antibiotics and the implementation of universal childhood immunisation programmes. Nonetheless, at least 50% of deaths in children between 1 month and 5 years of age globally are due to infectious diseases, the most common being lower respiratory infections, diarrhoeal diseases and malaria.5 One of the major advances of the last 50 years has been the development of new and improved vaccines targeted at many infectious diseases that particularly affect infants and young children. The most dramatic example is that of smallpox. Although Jenner discovered the vaccine in 1796, it was not until the 1950s that laboratory methods and public health infrastructure were such that rapid progress was made towards global eradication. The world’s last case occurred on 26 October 1977.6 Since the mid-1970s, the widespread establishment and implementation of the Expanded Programme on Immunisation (EPI) has led to remarkable achievements in controlling vaccine-preventable diseases world-wide. In the last 50 years, over 25 new vaccines or vaccine combinations have come into widespread use in Australia.7 During that time, there has been a marked reduction in the incidence of infections such as diphtheria,8 poliomyelitis,9 Haemophilus influenzae type b10 and many others. Immunisation is the subject of another article in this edition of the Journal.11 The last 50 years has seen the emergence of several new infections and a rapid increase in incidence or geographical range (re-emergence) of many others (Fig. 1).12 Examples of the former include human immunodeficiency virus (HIV) and severe acute respiratory syndrome, whereas West Nile virus in the United States and diphtheria in the former Soviet Union are examples of re-emerging diseases. Certain diseases such as anthrax have re-emerged through intentional introduction (bioterrorism). Imported cases of measles have led to a number of outbreaks in the USA and Australia in 2014, despite the disease having
Journal of Paediatrics and Child Health 51 (2015) 12–15 © 2015 The Author Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
M Starr
Infectious diseases: the last 50 years
• newly emerging diseases • re-emerging diseases • intentionally introduced Fig. 1
Examples of emerging and re-emerging infectious diseases (adapted from Morens et al.12).
been declared eliminated in both countries. Outbreaks of avian influenza (H5N1 and H7N9), pandemic influenza (H1N1) and more recently Ebola virus disease have caused appreciable morbidity and mortality and required significant public health responses occupying considerable resources in recent years. In 1981, the CDC issued a report of five cases of Pneumocystis carinii pneumonia in young homosexual males.13 It concluded: ‘The above observations suggest the possibility of a cellularimmune dysfunction related to a common exposure that predisposes individuals to opportunistic infections’. This was the first published description of the syndrome that was soon to be known as acquired immune deficiency syndrome or AIDS. In 1982, AIDS was reported for the first time in infants14 and HIV was identified in 1984. Childhood HIV infection and AIDS have continued to be a major global problem since then. In 2012, more than a quarter of a million children under 15 years of age were diagnosed with HIV, bringing the total number of children estimated to be living with HIV to over 3 million.15 More than 95% of HIV-infected children world-wide have acquired the virus via vertical transmission. For this reason, huge efforts have been invested in the prevention of mother to child transmission. The risk of vertical transmission can be reduced from as high as 40% with no intervention to
doi:10.1111/jpc.12795
REVIEW ARTICLE
Paediatric infectious diseases: The last 50 years Mike Starr Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia
Abstract: Many advances and challenges have occurred in the field of paediatric infectious diseases during the past 50 years. It is impossible to cover all of these in a short review, but a few highlights and lowlights will be covered. These include virtual disappearance of some infectious diseases, emergence of new ones, infections in the immunocompromised, antimicrobial resistance, development of new and improved antimicrobials, improved diagnostic tests and the Human Microbiome Project. Key words:
infectious diseases; HIV; microbiome.
Dating back to the 1st century CE, infections have been major causes of childhood morbidity and mortality, as they still are in the developing world.1 However, the discipline of paediatric infectious diseases was not recognised as a separate entity until the 1960s. Since then, the subspecialty has become more clearly defined and differentiated from the rest of paediatrics. In the first volume of the Australian Paediatric Journal in 1965, there were only three papers relating to infectious diseases, two of which dealt with tuberculosis (TB). A Case of Congenital Tuberculosis with Unusual Features describes the case of a 6-week-old baby who died of what was diagnosed at autopsy as TB.2 The mother, who already had seven children, was subsequently found to have tuberculous endometritis. Other members of the family were screened but did not have evidence of TB, at which point, ‘the mother admitted that this child was not by her husband’. The father was identified, and it was discovered that 2 months before the birth of the child, he had been treated for tuberculous epididymitis and pulmonary TB. The other two articles in 1965 were not quite as indelicate.3,4 In the last few months, the Journal of Paediatrics and Child Health has published over 20 articles relating to infections in children. It is impossible to cover all of the issues and advances in the field in a short review, but here are a few of the highlights and lowlights: • Virtual disappearance of some infectious diseases • Emergence/recognition of new infectious diseases (and re-emergence of old ones) • Global infectious disease epidemics • Infections in the immunocompromised • Emergence of antimicrobial resistance • Development of new and improved antimicrobials Correspondence: Dr Mike Starr, Department of General Medicine, Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Fax: 9345 4751; email: [email protected] Conflict of interest: The author has no conflicts of interest. Accepted for publication 8 October 2014.
12
• Improved diagnostic tests • The Human Microbiome Project A reduction in the global burden of infectious diseases has been a result of a number of factors including improvements in sanitation and hygiene, the discovery of antibiotics and the implementation of universal childhood immunisation programmes. Nonetheless, at least 50% of deaths in children between 1 month and 5 years of age globally are due to infectious diseases, the most common being lower respiratory infections, diarrhoeal diseases and malaria.5 One of the major advances of the last 50 years has been the development of new and improved vaccines targeted at many infectious diseases that particularly affect infants and young children. The most dramatic example is that of smallpox. Although Jenner discovered the vaccine in 1796, it was not until the 1950s that laboratory methods and public health infrastructure were such that rapid progress was made towards global eradication. The world’s last case occurred on 26 October 1977.6 Since the mid-1970s, the widespread establishment and implementation of the Expanded Programme on Immunisation (EPI) has led to remarkable achievements in controlling vaccine-preventable diseases world-wide. In the last 50 years, over 25 new vaccines or vaccine combinations have come into widespread use in Australia.7 During that time, there has been a marked reduction in the incidence of infections such as diphtheria,8 poliomyelitis,9 Haemophilus influenzae type b10 and many others. Immunisation is the subject of another article in this edition of the Journal.11 The last 50 years has seen the emergence of several new infections and a rapid increase in incidence or geographical range (re-emergence) of many others (Fig. 1).12 Examples of the former include human immunodeficiency virus (HIV) and severe acute respiratory syndrome, whereas West Nile virus in the United States and diphtheria in the former Soviet Union are examples of re-emerging diseases. Certain diseases such as anthrax have re-emerged through intentional introduction (bioterrorism). Imported cases of measles have led to a number of outbreaks in the USA and Australia in 2014, despite the disease having
Journal of Paediatrics and Child Health 51 (2015) 12–15 © 2015 The Author Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
M Starr
Infectious diseases: the last 50 years
• newly emerging diseases • re-emerging diseases • intentionally introduced Fig. 1
Examples of emerging and re-emerging infectious diseases (adapted from Morens et al.12).
been declared eliminated in both countries. Outbreaks of avian influenza (H5N1 and H7N9), pandemic influenza (H1N1) and more recently Ebola virus disease have caused appreciable morbidity and mortality and required significant public health responses occupying considerable resources in recent years. In 1981, the CDC issued a report of five cases of Pneumocystis carinii pneumonia in young homosexual males.13 It concluded: ‘The above observations suggest the possibility of a cellularimmune dysfunction related to a common exposure that predisposes individuals to opportunistic infections’. This was the first published description of the syndrome that was soon to be known as acquired immune deficiency syndrome or AIDS. In 1982, AIDS was reported for the first time in infants14 and HIV was identified in 1984. Childhood HIV infection and AIDS have continued to be a major global problem since then. In 2012, more than a quarter of a million children under 15 years of age were diagnosed with HIV, bringing the total number of children estimated to be living with HIV to over 3 million.15 More than 95% of HIV-infected children world-wide have acquired the virus via vertical transmission. For this reason, huge efforts have been invested in the prevention of mother to child transmission. The risk of vertical transmission can be reduced from as high as 40% with no intervention to
