Intended for healthcare professionals


Do we need a new approach to making vaccine recommendations?

BMJ 2015; 350 doi: (Published 30 January 2015) Cite this as: BMJ 2015;350:h308
  1. Natasha S Crowcroft, chief, infectious diseases1,
  2. Shelley L Deeks, medical director, immunization and vaccine preventable diseases2,
  3. Ross E Upshur, head, division of clinical public health2
  1. 1Public Health Ontario, 480 University Avenue, Suite 300, Toronto M5S 1A8, Ontario, Canada
  2. 2Dalla Lana School of Public Health, University of Toronto
  1. Correspondence to: N S Crowcroft natasha.crowcroft{at}
  • Accepted 12 December 2014

Controversy about the evidence, economics, ethics, lobbying, and decision making surrounding a new vaccine for serogroup B meningococcal disease should trigger change in the way we develop recommendations for new vaccines say Natasha Crowcroft and colleagues

We are on a steep trajectory away from an era of inexpensive vaccines for diseases that are widespread in the absence of immunisation. Vaccines are increasingly being produced for diseases that are devastating at an individual level but have less impact on population health. Moreover, the costs of developing and getting a vaccine to market are rising because of increasingly complex technologies and the public intolerance of adverse events. For these reasons new vaccines are likely to be less cost effective than older vaccines and are unlikely to be cost saving (fig 1).1

Fig 1 Newer vaccines cost more per life year saved than older vaccines. Currency: $C1; £0.5; €0.7; $0.8. DTP=diphtheria, tetanus, pertussis vaccine, HBV=hepatitis B virus screening and immunisation of newborns, MMR=measles, mumps, and rubella vaccine, PCV=pneumococcal conjugate vaccination for children, PPV=pneumococcal polysaccharide vaccine, VZV=varicella zoster vaccine. Source: Canadian Immunisation Guide.1

Technologies such as searching genetic codes for possible antigens and the development of new adjuvants to stimulate immune responses also bring considerable uncertainty about safety and effectiveness.2 It may take many years for adverse events caused by vaccines to be identified and confirmed, as was the case for the link between a pandemic H1N1 influenza vaccine (plus adjuvant) and narcolepsy.3 4

These challenges come at a time when some sections of society are less likely to vaccinate themselves or their children. Those who hesitate to vaccinate are often highly educated, well resourced, and demand respect for their perspectives.5 How best to reassure the public is unclear. But all the components of decision making about …

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