Historically, inefficiencies in production have limited the availability of newer vaccines outside of the developed world. For instance, acellular pertussis, while less likely to cause adverse reactions than its whole-cell counterpart, is also considerably more expensive because so much of the vaccine is lost during the manufacturing process. Yet, acellular pertussis may be a key element of successful technology transfer based on the DTP platform. There now are technologies available (involving pertussis toxin CRM), however, that can increase acellular yields threefold. The complexity and inefficiency of conjugation have similarly kept that technology out of the hands of developing-country vaccine makers. However, some manufacturers’ yields have jumped considerably over the past 2 years, and additional improvements are possible.

Technology transfer, bulk purchase, participation in revolving funds, and other approaches for getting vaccine to children in the developing world will have little impact unless these countries want to take these steps. Indeed, national commitment may be one of the most important, albeit least tangible, requisites for improving childhood immunization. The successful polio eradication experience in the Americas revealed the importance of high-level political consensus about the importance of childhood immunization. This political commitment was backed up by a financial one: Over the program’s lifetime, participating nations spent more than $500 million of their own money on eradication efforts. Conversely, political instability can have dramatic negative effects on public health initiatives. Such was the case recently in Nigeria, where measles immunization coverage rates for those under age 2 fell from a reported 80 percent to as low as 25 percent in some regions during a period of political unrest.34

Perhaps equally important to political commitment is popular demand. It is often only when there is grass-roots support for vaccination that barriers such as cost can be overcome. Public awareness of the need for vaccination sometimes can be misguided, however. This may have been the case in Brazil, which has recently purchased large amounts of group B meningococcal vaccine to battle endemic meningococcal disease but has opted not to buy Hib vaccine, which might have greater benefits over the long term.35

In the Americas, coordination was crucial to polio eradication, and similar cooperation between developing-world nations may be important as vaccine technology transfer moves ahead in other parts of the world. A revolving fund for vaccine purchase established by PAHO removed many hard-currency concerns during the fight against polio. The infusion of some $200 million from Rotary International also played a key role. In addition, during the eradication program, countries in the region developed close working relationships with


Catherine Oyejide.


Donald Shepard.

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