Infectious Diseases in 2020: 5 Areas of Concern

Paul G. Auwaerter, MD


January 14, 2020

This transcript has been edited for clarity.

Hello. I'm Paul Auwaerter with Medscape Infectious Diseases. 2019 has closed and we moved into 2020. There have been many important and exciting areas of advancement [in infectious diseases] but also areas of concern. As a clinician caring for patients, I think of these concerns fairly frequently. I also wear a public health hat, as many people in infectious diseases tend to do, and there are concerns in those areas as well.

High Cost of HIV Treatment

A year ago, the President of the United States kicked off an initiative to try to eliminate HIV, which is exciting. Now that therapy has improved, many of our patients only need a single pill. However, this initiative—much like for hepatitis C, the treatment for which has gotten relatively easy and straightforward—has problems, such as cost. Other issues include government support and funding for initiatives, and finding patients who are transmitting disease and are not in therapy.

Mathematical models suggest that everything is very possible. From a cost-benefit basis, it would probably benefit our country. However, with real tax dollars and costs always at the forefront, health infrastructure for public health and individuals usually takes a back seat, sadly. I'm hoping such efforts will continue.

Antimicrobial Resistance

Antimicrobial resistance concerns many of us as well as our patients. We're finding increasingly resistant pathogens, and the World Health Organization has labeled this as a top health threat. With government support, BARDA (Biomedical Advanced Research and Development Authority) and other agencies have helped a number of smaller companies with basic research and development to bring new drugs to market, including cefiderocol, plazomicin, imipenem-relebactam, and many others.

The concept of getting multiple drugs to market looked quite bleak 5-10 years ago but is now a reality. The problem has been that no one in the pharmaceutical industry finds these drugs to be profitable. We tend to restrict drugs appropriately as part of stewardship, but we have not found an appropriate model.

The European Union and other countries are concerned about these initiatives. How to help solve this has remained a very difficult issue, as politicians are not willing to see that helping pharmaceutical companies is something that's palatable. Trying to figure out how to move forward and have effective drugs that we can actually purchase and use, that are FDA approved and maintained in the marketplace, remains very difficult and concerning.

Vaccine Hesitancy

Vaccine hesitancy is a growing concern. American Samoa, where there has been a huge measles outbreak in 2019, is one area outside the United States where not having sufficient immunization coverage is a great concern. I do not think this will go away.

As our society gets more technologically adept with growing amounts of facts and difficulties, I think many people try to effect control by saying no. This is almost like a chronic health model where patients with chronic illnesses find that they can gain some sense of control by saying no and underestimating health risks instead of dealing with fears or unknowns. This will need continued efforts, and it's important that vaccine initiatives are not dropped because of this growing concern.

A real positive this past year has been the success of the Ebola vaccine in Congo, which was recently approved by the FDA, along with anti-Ebola medications that have also proved effective. These are tremendous improvements. I think immunizations remain a low-cost and effective way forward on many fronts, with improved influenza vaccines hopefully at the forefront.

Immunization Practices

The next area involves some interesting changes in immunization practices. For the first time, a vaccine has been walked back—the pneumococcal conjugate vaccine for average-risk adults aged 65 years or older. It is now a shared-decision model as to whether you administer it after the pneumococcal vaccine. That's not something that we've faced before.

There is controversy about this, mainly because of the success of reduced pneumococcal disease in children, who were probably a big component of transmitting strains to older adults.

I think whether people will continue giving the vaccine routinely has not yet been fully fleshed out. The cost-benefit analysis seems to be wanting in most cases. Personally, I've stopped recommending it to most patients after pneumococcal vaccine.


There have been some exciting developments in influenza with adjuvant vaccines and higher doses for populations aged 65 years or older. Work on new angles toward improving immunization should be well funded, as this is a disease that affects more people per year than any other, and strategies could have such a high payoff.

A new anti-influenza drug, baloxavir, is a cap-dependent endonuclease inhibitor that works early in the viral lifecycle. Most patients are likely to benefit from very early administration, but stay tuned. Over the next year, we may learn more from combination studies where that drug or similar drugs are combined with neuraminidase inhibitors to see if they're more effective in our treatment of patients who are very ill with influenza.

Thanks very much for listening. I wish everyone the best for 2020. I'm looking forward to new and exciting developments, which are the reasons I find this field so important and very attractive. I hope our younger trainees continue to find this interesting. Thank you.

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