Evolution, benefits, and shortcomings of vaccine management.

BACKGROUND The reduction of childhood mortality by vaccines has been one of the greatest public health successes of the past century. However, many targets for immunization remain uncontrolled, and new or improved vaccines are emerging to meet these challenges. OBJECTIVE To review the evolution of vaccination and take an objective look at current vaccine development technologies, thereby framing the discussion of vaccine management. SUMMARY The genesis of vaccinology is generally considered to have been a direct result of the observation that persons who had contracted smallpox rarely developed a second case. From this observation, the concept of variolation was born, which involved the inoculation of uninfected individuals using material collected from smallpox lesions with the goal of inducing immunity to future infection. The use of attenuated, live virus to induce immunity was the next step in the evolution of vaccinology, followed by inactivation of the virus when diseases caused by organisms not amenable to attenuation were targeted. More recently, a variety of adjuvant strategies have been developed to improve the immunogenicity of inactivated vaccines, and genetic engineering has been employed to increase the safety, reduce the reactogenicity, and improve the immunogenicity of different vaccines. CONCLUSION Clinical (efficacy and safety) and economic (cost and profit) considerations are competing priorities that need to be reconciled within a discussion encompassing the government, the public, the pharmaceutical industry, third-party payers, and private individuals or companies who administer these vaccines.