The Future of Vaccines
Reflections from the IOM’s Annual Meeting
Vaccines represent a remarkable set of innovations that have saved countless lives. This unwavering sense of success defined this year’s IOM Annual Meeting, “Vaccines: The Science, Policy, and Practice of Immunization.”
The meeting was an opportunity to both relish recent accomplishments in immunization such as the roll out of the Meningitis A vaccine in Central Africa, the hopefully permanent drop in polio cases in India and the global increase in DTP3 coverage, and to step back and critically consider the challenges and opportunities that lie ahead in maintaining momentum for existing vaccine programs and in developing and rolling out new ones. Distinguished vaccine heavyweights like Bill Foege recalled the lessons of the smallpox eradication campaign and urged other experts to take on the fight for measles eradication. Seth Berkley, the new CEO of the GAVI Alliance, shared GAVI’s plan to expand global vaccination through country co-financing and price negotiations. All of the panelists and speakers agreed that vaccination is one of the most cost effective public health interventions available, and as a bonus, offers an entry point into local communities to promote other health services. I was impressed by the commitment of the experts in the room to combatting disease and perhaps even to take on the daunting idea of new eradication efforts. The speakers emphasized that any future large scale immunization or eradication effort must first identify lessons and gaps from previous initiatives.
A major lesson that the speakers returned to again and again is the need for better real-time health data – both on the incidence and prevalence of disease and on vaccination coverage. Disease surveillance is particularly important for elimination and eradication campaigns. The current push for polio eradication has created a cadre of field staff who have learned how to penetrate isolated communities. Their local knowledge could be critical for future vaccination efforts, but follow-up data collection must be equally as extensive in order to accurately measure success. And as progress toward vaccination coverage target advances, sound data is important to guide (increasingly challenging) efforts to reach unvaccinated children (the so-called “last mile” problem). Global immunization coverage rates are estimated from a mix of administrative and household survey data. The quality of this information can considerably vary. GAVI’s financing policy requires countries to reach certain immunization benchmarks, and even makes some of their funding performance-based. But to do this responsibly, accurate measurement of coverage rates are critical and current rates are challenging to verify.
New vaccination campaigns will also require new vaccines. Until recently, vaccines have largely focused on childhood diseases, but now vaccines are expanding to other stages of the life course (like the HPV vaccine targeting adolescents). The science behind vaccines has similarly evolved. The earliest vaccines were based on empirical observations of natural immunity, then developers moved onto recombinant and conjugate vaccines, and the next generation of vaccines will be even more complex. Candidates that are currently in development like the malaria and AIDS vaccine are already pushing the envelope of what’s possible.
Two essential points emerged as obstacles that could derail global vaccination campaigns even if the science and operational research are fully mastered—financing and vaccine hesitancy. Both relate to culture and human behavior. People (governments, insurance programs, patients and taxpayers) have to be willing to pay for vaccination, and individuals must be willing to receive them.
As Seth Berkeley pointed out, GAVI is doing its best to prioritize spending, control prices and encourage country co-financing in order to support new vaccine adoption without losing coverage for existing vaccines, but it is important that public and private donors continue to support vaccines as a critical tool in disease control. It’s easy to forget that it has only been a decade or so since the Gates Foundation entered the scene and revolutionized the funding available for vaccine development and GAVI was established as an independent unique global alliance to finance vaccine adoption in the developing world. GAVI’s recent replenishment is clearly a promising sign as donors mobilized an additional $600 million above the Alliance’s original $3.7 billion target, but it remains to be seen whether vaccine financing will suffer if the looming global health funding crunch that many people fear comes to pass.Vaccine hesitancy, or patients’ prohibitive mistrust of vaccination, is a ubiquitous problem affecting countries from the US to Nigeria. This is a problem perpetuated by misinformation and the politicization of immunization. Some suggest that in the U.S. the population has forgotten the horrors of infectious diseases like measles and polio and as a result, grossly misjudges risk. The rationales for vaccine hesitancy differ by location, but clear and accurate communications campaigns and honest positions from local leaders are badly needed. Eradication (and even control) campaigns cannot succeed without widespread acceptance of vaccines.
At end of the meeting, one thing was clear—when champions and advocates can bring all of these links together, the results are inspiring. In his closing remarks, President of the IOM, Harvey Fineberg, noted that vaccines are the “quintessential silent success of prevention.” Despite the immense amount of financing, science and field work that enables vaccine adoption behind the scenes, when they work, they save lives without any fuss.