Do we need a new approach to making vaccine recommendations?

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

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 …