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routes (e.g., oral, intranasal, or cutaneous delivery) should receive consideration. At the same time, the committee knows that market forces and corporate alliances will drive the availability of combination products.

The committee’s analysis demonstrates that not all candidate vaccines will save money. Some new vaccines might be very expensive to purchase and develop. The target population might be very small. However, the health benefits for some people might still be compelling. Use of these vaccines will require a shift from an expectation that vaccines are always cost-saving to an acknowledgment that the health benefits of some vaccines might be worth the cost. Many vaccines are not covered by health care plans—neither indemnity plans nor managed care. Financial incentives to insurers or to individuals might be crucial for encouraging the use of vaccines.

However, the cost of vaccines to the individual and to insurers is not the only impediment to vaccine use. Vaccines, like other public health successes such as clean water, fluoridation to prevent caries, and food safety measures are a victim of their own success; people forget how dangerous vaccine-preventable disease can be and become complacent. This false sense of security strikes individuals, communities, health care providers, and policymakers. It is not until the system fails and illness surges (such as with antibiotic resistance, nosocomial infections, the measles outbreaks that occurred in the late 1980s, or food-borne illness) that we pay the price for interventions, such as vaccines, that are not yet developed or implemented.

The committee urges careful consideration, but not rigidity, in the use of evidence-based approaches, such as the qualitative framework and quantitative model developed for this report, for prioritization of research, development, and use of vaccines as well as other preventive and therapeutic interventions. The committee, while acknowledging the limitations of modeling exercises in general and of the one it developed and used in particular, does believe that modeling is useful and important when attempting to compare widely divergent vaccine-preventable conditions. It hopes that the inferences derived from the model will be useful to the vaccine science community, vaccine manufacturers, and research and program policymakers.

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