Ruth L. Berkelman, MD, has been Deputy Director of the National Center for Infectious Diseases since 1992. She led the effort to develop a national plan to combat emerging infectious diseases. Berkelman joined the Centers for Disease Control and Prevention (CDC) in 1980 as an epidemic intelligence service office in the Hospital Infections Program. From 1988 to 1992, she served as Chief of the Surveillance Branch in the CDC's Division of HIV/AIDS.
April 1996
Many emerging infections in children are same as those in adults. They include HIV, tick-borne infections, such as Lyme disease, antibiotic-resistant pneumococcal infections, invasive infections caused by group A streptococci, such as streptococcal toxic shock syndrome and necrotizing fasciitis, and infections due to Escherichia coli O157:H7. In fact, infections caused by E coli O157:H7 have become the major cause of acute kidney failure in children. We're also seeing more clusters of meningococcal C in children than we've seen in the past. These clusters have appeared in places all over the United States. In addition, otitis media is on the rise. From 1975 to 1990, the number of children visits to see doctors for ear infections increased from 10 million to 24 million.
Ehrlichiosis, which is a tick-borne disease, is an emerging infection. The disease has been seen mainly in adults, but many researchers believe that once diagnostic tests for this disease become widely available, ehrlichiosis will be diagnosed more frequently in children and adults.
We're seeing a need for increased post-exposure treatment in both adults and children who have had contact with rabid animals, particularly with raccoons in the Northeast. In New York State in 1989, for example, fewer than 100 people were reported to have received rabies-exposure shots. In 1993, close to 3,000 people received those shots. It is quite a remarkable increase.
Human rabies cases do not occur in high numbers, but they have turned out to be extraordinarily costly to communities in terms of post-exposure treatment. Because a pet store in New Hampshire had a rabid kitten, more than 500 people, many of them children had to be vaccinated against rabies. It costs about $1,000 to vaccinate somebody against rabies. In some communities, post-exposure treatments account for about 10% of the cost of rabies control.
Although certain illnesses are becoming more common in children, others have been declining in part as a result of routine immunizations. Haemophilus influenzae type b, once the major cause of meningitis in children, has practically been eliminated in young children.
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Important factors probably include day care attendance, increasing microbial resistance to antibiotics, and the debut and spread of invasive bacterial strains. Enrollment of children in day care has grown tremendously in the past two decades. The risk for many respiratory and diarrheal illnesses goes up considerably for a child in day care. We have seen outbreaks of E coli O157:H7 and cryptosporidiosis in day care centers.
Changes in food technology are largely responsible for growing problems with E coli O157:H7. Mass food production made it possible for a small amount of meat to contaminate large quantities of meat.
In the late 1980s, in part due to complacency about measles, levels of measles immunizations began to go down, and we started seeing a rise in the number of measles cases. Rheumatic fever also recently had a resurgence, emphasizing the need for accurate diagnosis of strep throat.
Pediatricians can play a real role educating parents and schools officials about basic hygiene, such as washing hands and not sharing combs and hair brushes. Anecdotal reports suggest that some places in the United States are having a growing problem with lice. We're seeing an increase in Shigella in the southeastern United States, and this could be addressed in part by improvements in hygiene.
Pediatricians also can inform parents who smoke about how second-hand tobacco smoke exposes their children to increased risk of respiratory illness.
Furthermore, pediatricians can take a harder line on the use of antibiotics. Pediatricians must make sure that they only use antibiotics when they are really necessary, and not cave in to parents who demand that antibiotics be prescribed. Pediatricians probably need to explain that these antibiotics, to maintain their usefulness over time, must be used only when they are appropriate.
Pediatricians need to inquire about travel to ascertain if a child's illness was contracted outside the United States. Travel to certain places outside the United States could expose children to exotic diseases. For example, parts of the Caribbean and Central and South America are having a large dengue outbreak. When children present with certain symptoms, pediatricians should ask about exposures to animals, such as household pets. Cats can transmit cat scratch disease. Iguanas can transmit salmonellosis.
Pediatricians need to work with local and state health departments to report unusual diseases and unusually large numbers of cases of certain diseases. Alert pediatricians are often the first ones to detect new epidemics. Pediatricians should keep up and be aware of new illnesses, such as ehrlichiosis, and be alert to their occurrence. It's really through pediatricians that public health personnel know whether an illness is a major problem or not in children.
In 1995, the CDC launched an emerging infections program in four states, Oregon, Minnesota, California, and Connecticut. The programs are monitoring all invasive infections from pneumococci, group A and group B streptococci, meningococci, and Haemophilus influenzae type b, as well as food-borne illnesses. Other projects focus on identification, prevention, and control of community-acquired pneumonia, ehrlichiosis, and cryptosporidium. The federal government gave the CDC $7.7 million to start implementing its plan in 1995, and allocated $10.7 million more for 1996. The CDC projected that the plan, which will take 5 years to implement, will cost $125 million.
We need better diagnostic tests, especially for respiratory infections. When a child walks in the door, the children may have otitis media or pneumonia and we don't know the organism causing it or its drug susceptibilities.
Such tests would give a better sense of what drug to treat a child with and could delay the development of drug-resistant organisms. We need to know if reducing the level of antibiotic use will prolong antibiotic usefulness.
If pneumococcal resistance becomes a more severe problem, we will have to step up efforts to develop and use a conjugate pneumococcal vaccine. The licensed pneumococcal vaccine is for children older than 2 years. The greatest of incidence of severe pneumococcal disease in children, however, is in children younger than 2.
We also should try to determine the frequency and symptoms of ehrlichiosis in children.
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