Intended for healthcare professionals


Rethinking global access to vaccines

BMJ 2008; 336 doi: (Published 03 April 2008) Cite this as: BMJ 2008;336:750
  1. Dave A Chokshi, medical student 1,
  2. Aaron S Kesselheim, instructor in medicine 2
  1. 1University of Pennsylvania School of Medicine, 3434 Sansom St, Philadelphia, PA 19104, USA
  2. 2Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
  1. Correspondence to: D A Chokshi daveash{at}
  • Accepted 16 January 2008

Barriers to dissemination of life saving vaccines in low income countries can and should be overcome, argue Dave Chokshi and Aaron Kesselheim

Inadequate access to vaccines in low and middle income countries results in more than two million deaths each year.1 Two thirds of these deaths occur in children under the age of 5. Hepatitis B virus and Haemophilus influenzae type b (Hib) vaccines are now starting to be used in low and middle income countries, but they were licensed for use in the industrialised world more than two decades ago. Our difficulty in disseminating well established vaccines casts doubt on our ability to promote widespread use of new ones, such as those for diarrhoea associated with rotavirus infection and for human papillomavirus (a causative agent of cervical cancer) (table). Currently, over 99% of the 440 000 annual deaths from rotavirus associated diarrhoea and 93% of the 260 000 annual deaths from cervical cancer occur outside the 60 wealthiest countries.2 3

View this table:

Development and dissemination of rotavirus and HPV vaccines

Challenging widely held beliefs

Three arguments have historically dominated discussions about the cause of unequal access to vaccines in poorer countries: the primacy of healthcare infrastructure; constraints imposed by insufficient funding; and the belief that vaccine approval in high income countries is a precondition for discussing access in other settings. Recent experiences have shown how each of these contentions is open to challenge.

Primacy of infrastructure

Must poor healthcare infrastructure be addressed before large scale vaccination can succeed? The claim that poor infrastructure is a more fundamental—and therefore more pressing—problem than access to vaccines must be distinguished from the claim that local logistical hurdles must be overcome to achieve equitable access. Those who agree with the former contention believe that ensuring supplies of food and clean water and building roads will do more for public health …

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