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Successes and Failures Final PDF
Successes and Failures Final PDF
Biologicals
journal homepage: www.elsevier.com/locate/biologicals
Review
a r t i c l e i n f o a b s t r a c t
Article history: The impact that vaccines have had on world health has been great. The misery prevented and the lives
Received 24 May 2010 saved have been impressive. But all has not been good. As one looks at the success, one can also see the
Received in revised form missed opportunities. This discussion takes a broad, worldwide view of vaccines - from early research,
17 June 2010
through development and application. It examines our successes and our failures and looks with great
Accepted 29 June 2010
optimism towards a future having great potential to prevent much of today’s suffering from infectious
diseases.
Keywords:
Ó 2010 The International Association for Biologicals. Published by Elsevier Ltd. All rights reserved.
Vaccines
International
Success and failure
Vaccines are such wonderful tools of medicine. Because of their But it has not been easy. The process of vaccine development,
use, the horrors of many diseases such as smallpox, diphtheria, from basic research to uncover disease etiology, through vaccine
tetanus, measles, diarrhea and meningitis, have, in many areas of construction and pre-clinical and clinical testing, to actual appli-
the world, been relegated to the past. No doubt, the progress has cation and disease control, is arduous. It is technically challenging,
been great and the misery prevented and the lives saved have been expensive and time consuming.
impressive. But all has not been good. As one looks at the success, Yet the ultimate rewards are indeed great. Diseases of great
one can also see the missed opportunities. This discussion will take morbidity and mortality one day can be all but forgotten the next.
a broad view of vaccines e from early research, through develop- Again, take smallpox. It was a horrible disease. Dr. Edward Jenner’s
ment and application. The focus, for obvious reasons, will be vaccine was based on the observation that ONLY the milkmaids of
worldwide as these infectious diseases do not respect national 1700 England had faces free from the pock marks of the disease.
borders and, as a result, vaccine developers and users must view Instead, these milkmaids had pocks of their hands from previous
the world as a single place where humans and animals interact in infections from cowpox virus that protected them. Everyone else,
an environment full of potentially dangerous infectious agents. from princes to paupers [1], had either died or was marked by the
The bio-technological advancements over the years have given smallpox virus itself. Ultimately, the epidemiological under-
us laboratory powers to understand disease etiology and produce standing that humans were the only host for smallpox, combined
newer and better vaccine products and newer and better ways to with advances in vaccine manufacturing and delivery technologies,
deliver them. The results have been astounding e including the led to the global commitment to eliminate the disease. But such
total eradication of one of human-kinds most dreaded scourges e technology and commitments alone were not enough. The brilliant
smallpox e and the prevention of a myriad of other dangerous strategy of “search and containment”, brought forth by Foege,
infectious maladies. Indeed, the advancements in microbiological Millar and Lane in eastern Nigeria in the 1970s [2], allowed for the
techniques, the better understanding of disease etiology, disease eventual elimination of that disease from the world.
occurrence and the subsequent development of tools for their Although smallpox is the only disease to have actually been
prevention, have been nothing short of revolutionary. These tech- eradicated, there are more that, through the application of vaccines,
nical advancements, linked to the more recent increase in invest- have seen marked reductions if not total eradication. The explosion
ments by foundations, governments and not-for-profit institutions of vaccine development in the last 50 years has seen diseases like
in vaccine development and delivery, have been nothing short of polio being pushed into ever decreasing regions of the world.
phenomenal. Others, like whooping cough are never seen in industrialized
countries until unwise anti-vaccine movements bring the rates of
* Tel.: þ1 650 228 7909; fax: þ1 650 228 7901. vaccine coverage down enough to allow its return. And diphtheria,
E-mail address: [email protected]. tetanus and yellow fever are seldom seen by most physicians
1045-1056/$36.00 Ó 2010 The International Association for Biologicals. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.biologicals.2010.06.003
Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
doi:10.1016/j.biologicals.2010.06.003
2 D.P. Francis / Biologicals xxx (2010) 1e6
outside of less developed countries (LDCs). More recently child- Yet it took over 25 years to reach 65% of the population in adopter
hood meningitis and hepatitis A and hepatitis B are following the countries (Fig. 2).
same path. Equally spectacularly, thanks to the ingenious and For each of these vaccine-preventable diseases, the delay in
energetic pursuit of researchers, others like cervical cancer, will delivering vaccine resulted in millions of suffering and dying children.
hopefully follow soon. To fully understand the real costs and reasons for the delays of
When added together, the contributions to world health from preventing these diseases, let’s take a broader look at vaccines e
these remarkable products is nothing short of astounding. Whether from initial development to population-wide application. At the
considered in lives saved, health resources saved or person years of earliest stages, we need to fully understand all of the steps and
life saved, vaccines are some of the best investments that societies costs involved in vaccine development.
can make [3]. Note here that I use the term “development” e meaning those
So that’s the good news. Now let’s look a little deeper and efforts which take place after the fundamental “research” has
explore where, despite the overall good news, we can see where we uncovered the cause of a specific disease. It is important to make
missed the mark on some scores. First let’s look not just at how the distinction here between the two activities (research and
much we have progressed but how long it has taken us to get there. development) for each has very distinct output measures. In the
Again, we can start with smallpox, a horrific disease that everyone 2001 World Bank Report on vaccines, McKinsey and Company
at risk shuttered at the thought of. Early vaccination started in 1791 described the distinct output differences between institutional
while vaccine became widely available by the early 1900s. Yet, it basic science research and actual product development by
took decades longer to totally eliminate transmission in North industry: “The public sector institutions involved in vaccine R&D
America and Europe (between 1930 and 1950) and years more to are primarily focused on basic science knowledge diffusion, rather
eliminate it from the rest of the world (in 1977). than single-mindedly solving applied development problems to
Polio, the second disease chosen to be eliminated has shown ensure large scale, consistent production. The incentives in the
a similar pattern. Polio vaccine was first licensed in 1955 and was public sector reinforce this knowledge focus and are generally
eliminated in the US and Europe after 36 years. Yet for the rest of the inconsistent with efficient production of commodities”.
world, it persists in 2010, 55 years after the vaccine was licensed. In other words, the primary role of public sector academic
For both of these diseases, although safe and effective vaccines research institutions is to focus on discovery and the outputs of
were available, they were not provided to many of those at risk and, their efforts are judged by the amount of knowledge they accu-
as a direct result, immense numbers of cases and deaths occurred mulate as measured by the number and value of the research
during these intervals. For example, at the time the World Health manuscripts they publish in the scientific literature. On the other
Assembly called for smallpox to be eradicated in 1967, an estimated hand, the role of industries is the actual development and manu-
13,100,000 cases occurred annually in the 33 endemic countries [4]. facture of products. Their output will be judged by the number of
Similar costly delays have occurred with essentially all vaccine- products (in this case, vaccines) they actually develop and deliver
preventable diseases. Again let’s take one of the oldest e the and, in the case of the private sector, the level of profits they receive
standard DPT vaccine used since the 1940s. Worldwide low from selling these products.
coverage levels (<20%) existed until 1980 (Fig. 1) when interna- The lessons here are several. First, if societies want new vaccines
tional support was initiated. The result: by 1990, worldwide they need to have and support both arms of this greater development
coverage reached 75%. Similarly, for hepatitis B there was initial process e the early academic “discovery” arm and the later, industrial
slow worldwide delivery. This vaccine was first licensed in 1980. “development” arm. Both are essential if societies are to have safe and
Fig. 1. WHO Region-specific immunization coverage with 3 doses of DPT between 1980 and 2007.
Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
doi:10.1016/j.biologicals.2010.06.003
D.P. Francis / Biologicals xxx (2010) 1e6 3
Fig. 2. Global hepatitis B vaccine. Number of countries introducing vaccine and percent of infants receiving 3 vaccine doses. 1989e2007.
effective vaccines. Second, all involved must understand the amount therapeutic medicinal development, these executives have a choice
of time and money required to bring these vaccines from the bench to of investing their resources into a variety of development projects.
the people. Time can be measured directly. Cost data, on the other To make such decisions from the plethora of projects presented to
hand, are more difficult to obtain from industry. Such information is them, they will need to explore the likelihood of technical success
not readily available for most vaccines. Yet, recently, two companies of each project combined with an estimate of financial return
have released some cost data that can be used as examples. One, should the project be successful. Here is where the influence of
VaxGen, reported on the costs of its failed HIV vaccine. They stated social value comes into play. Pharmaceutical executives are very
that their total costs, through phase III, were approximately $300 aware that when citizens get sick, they or their relatives are often
million [5]. The other company, Aviron, reported the costs required to insistent that the best that medicine can offer should be delivered.
develop their Flumist nasal influenza vaccine. Those costs were esti- In other words, people give curative medicine high priority.
mated to be $340 million for a fully licensed product [6]. For both of In contrast, preventive medicine and the vaccines that are
these products, the time from bench to end of phase III testing and/or required for it, get much less interest. Preventative medicine is of
licensure took a decade or more and we can be assured that by the the future while curative medicine is very much of the moment.
time the final product would have reached the street, the costs would And most governments, certainly elected ones influenced by indi-
be two to three times higher. viduals or organizations insisting on immediate cures, are very
Despite the limits of available information, we can certainly much focused on the short-term moment. Support for vaccine
conclude that successful vaccine development takes a great deal of development and use depends on a mature and educated group of
time and a great deal of money. What then spurs societies to make experts who review data and make recommendations for devel-
such an investment? In the end, it is social value. If the society opment and use. Unfortunately, such experts are often far removed
values what they receive from vaccines and the prevention of from the political powers that ultimately make the financial deci-
disease that follows, they will continue to invest in future devel- sions on which successful vaccine purchase and delivery depend.
opment. But this may be an oversimplification. In the real world, Before the reader becomes irritated by the lack of interest in
things are more complex. Fundamental in gaining an under- vaccines coming from commercial pharmaceutical/biotech
standing of the complexity is seeing the difference between disease companies, let’s take a moment to sit in on a theoretical pharma-
treatment and disease prevention. Everyone understands disease ceutical company Board of Directors meeting. On that Board,
treatment e someone develops symptoms of a disease, is brought members have the legal responsibility to protect the financial
into the medical system to be diagnosed and given appropriate interests of their investors. At this Board meeting members are
medical treatment. For prevention, a more subtle understanding is presented with two proposals for support of two multimillion
required, unless a raging disease epidemic is occurring in a pop- dollar projects. One is for a vaccine for a worldwide disease for
ulation. Under normal conditions, people have to intellectually which the protective immune responses are not known. An
understand that there is a hidden risk of a given disease and that, exciting, very sharp investigator from the company presents a plan
with such a risk, they should ensure that all of their children receive to understand the disease and make a vaccine for it. The second
vaccines to eliminate the risk. Furthermore, everyone must investigator makes a pitch for support for his cancer therapeutic
understand that, like the medical treatments they demand, product where, again, the etiology is unknown, but recent research
vaccines cost money and someone, either our governments or has demonstrated the expression of a unique surface protein in 25%
ourselves, must come up with the money to pay for them. of cases against which the investigator has already produced
Here is where the system, at least viewed from the vaccine several monoclonal antibodies (MAbs) that could bind to the cancer
industry perspective, has failed. Industry executives’ major objec- cells and potentially decrease the risk of death.
tive is to maximize the company’s profits for their investors. Given Let’s assume the costs of each project are the same, approxi-
that many of the technical skills required for successful preventive mately $300 mm to market. After the scientists have left the Board
vaccine development and production can be applied equally well to meeting, the company’s business person outlines the potential
Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
doi:10.1016/j.biologicals.2010.06.003
4 D.P. Francis / Biologicals xxx (2010) 1e6
profits from each of these proposed products. Bottom line, comes from such poorly conceived cost studies, we will never be
assuming equal probability of technical success, the anti-cancer able to appropriately prioritize the value of vaccines against agents
MAbs can be priced very high (similar to other cancer therapeutics) having long incubation periods.
with a very clear market in industrialized countries with very rapid Now let’s narrow our focus from the whole world to just the less
use once licensed e even if the target protein is expressed in only developed countries (LDCs). In these areas, the importance of
25% of cases. In contrast, for the vaccine, although very important vaccines in preventing disease can hardly be exaggerated. Whether
and likely to do great good for large numbers of people, the speed of judged by the number of people at risk of infectious diseases or the
uptake will depend on an unknown private sector market together burden of vaccine preventable diseases, those living in less devel-
with an even less dependable public sector market. Decision made. oped countries suffer the most (Fig. 3). Despite LDCs having this
Follow the therapeutic market and recommend the vaccine team extraordinary burden of vaccine preventable diseases, the largest
re-direct its research to therapeutic agents. market, as defined by financial return from vaccine purchase, has
The sad “bottom line” of this hypothetical, yet far too often been the industrialized countries. Fully 82% of the annual $6 billion
”real”, scenario is that orders of magnitude increases in public vaccine market comes from sales of vaccines in industrialized
good would likely be achieved by the opposite decision. Vaccines, countries. In actuality, the public health benefit to the people of
over the years, have been extremely cost effective tools for both these wealthy countries has been quite remarkable. Indeed the
saving resources and preventing suffering and death. The problem resulting decrease or elimination of multiple terrible diseases has
here is not the pharmaceutical industry. They are doing what they been a great accomplishment. And the return to the vaccine
should e following the “values” (what we will pay for) of the industry for their labors of several billions of dollars is something
society. The problem is that today’s societies, given the political that should not be dismissed. Such returns should serve to hope-
systems that guide them, have great difficulty acting where long- fully re-energize the development of additional vaccines for
term benefits are often beyond the intellectual, political and diseases that continue to plague that part of the world.
business capacities of the system to deal with. Looking at this reality another way, however, we can see, as
As a result of this “market failure”, in actuality a social failure, recently as 2001 (Fig. 4) that, although all vaccines taken together
industry often sees valuable vaccines as being undervalued and not had a reasonable size market, that market (of all vaccines) was of
worth pursuing. the same size as the market for single drugs such as LipitorÒ or
Why does “society” undervalue vaccines? Here the system PrilosecÒ. When compared to the equivalent sales in the less
seems remarkably failure prone. Wealthy people, especially in developed countries, the problem becomes more than apparent.
industrialized countries where most vaccine-preventable diseases Left to market forces alone, the people of less developed countries
occur at relatively low incidence, have little immediate incentive to will suffer and die of easily preventable diseases. Although vaccines
immunize their children. Here the remarkable success of vaccines have great potential to prevent disease, they are expensive and time
has, ironically, undercut the value given by these societies for consuming to develop and companies that invest in this develop-
vaccines. People in industrialized countries rarely have any expe- ment will logically seek products that will give better returns on
rience with the horrors of these diseases. Only when overly- their investments in those countries that have financial resources
protective parents refuse to vaccinate their children do these to give such returns (Table 1).
preventable diseases re-surface [7,8]. Less wealthy people in To solve this problem, we have to use other forces than those of
industrialized countries may, themselves, appreciate the value of classic supply and demand. These other forces have been
vaccines more, but are dependent on chronically underfunded commonly referred as “push” and “pull”. That is, if the standard
public health departments to deliver vaccines to their children. supply and demand forces do not stimulate important vaccines to
But why are public health departments underfunded? Here we be developed or used in LDCs, then resources have to be directed to
return to the previous discussion comparing the public’s interest in either “push” new products through development with direct
“preventative” versus “curative” medicine. When individuals, funding or, for those already in the market, “pulled” into use by
authorities or businesses are faced with hard decisions as to which direct purchasing of vaccines for delivery in LDCs. Through the
of these they are going to fund, often the short-term curative years, there have been some remarkable successes for the push
medicine side wins. Although understandable from the emotion-
of-the-moment decision process that is used, it makes very little
sense from the full vantage point of long-term public good.
There is another culprit that comes into play here e cost-benefit
and/or cost-effectiveness analysis. These analyses, especially for
those of us involved in long-incubation communicable diseases, are
especially irksome. To highlight the potential for misguided advice
given by these analyses, let’s take a communicable agent that, after
a long incubation period, is both communicable to others and,
produces deadly disease in those infected. If this deadly disease
takes 30 years post infection to develop (e.g. primary hepatocellular
carcinoma following HBV infection), and a conservative discount
rate of 5% per year is used, then, with this model, there is little or no
predicted value of vaccinating to prevent the infection. Further-
more, as often occurs in this type of modeling, no added value is
given to preventing subsequent infections that often come from
being in contact with people suffering from these infections. There
is often no realization that these slow progressors are, importantly,
the source of infection for the next generation of cases. They ignore
the fact that, if one could prevent the infection of the source, one Fig. 3. The global vaccine market, global disease burden of vaccine preventable
would also prevent the next generations of cases in the future. If diseases and investment in vaccine research and development. Comparisons of
decision makers continue to ignore the nonsensical data that often industrialized and developing countries (Courtesy P. Whitehead).
Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
doi:10.1016/j.biologicals.2010.06.003
D.P. Francis / Biologicals xxx (2010) 1e6 5
Table 1
Push: Public Private Partnerships in the Past.
Pasteur Institute
Diphtheria, TB, pertussis, tetanus
Rockefeller Foundation
Yellow fever
Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
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6 D.P. Francis / Biologicals xxx (2010) 1e6
have involved early research on which development is built. Others effective products still cost hundreds of millions of dollars to develop.
have established cooperative arrangements with industrial part- Yes, there are ways to do it more economically and these should be
ners to accelerate development. Others have taken on the respon- taken advantage of. Nevertheless, vaccine development is expensive
sibility to speed access once vaccines are developed. For a review of and, in order to save lives and reduce the costs of disease, the world
these efforts, see the 3rd edition of “State of the world’s vaccine and must be willing to put up the necessary resources to make it
immunization” [10] and the partial list. successful.
Although this is a very exciting and ever-changing time for LDC This is true both for the development of the new vaccines and
vaccine development, looking ahead, one can visualize many their purchase once developed. One challenge, here, will be shifting
challenges yet to be confronted. These challenges will be both more of the purchasing responsibility for older vaccines to national
structural and financial. One key element will be to continue to and local authorities rather than international organizations. The
expand and perfect the capability of today’s vaccine delivery international organizations will be the only ones that can fund the
systems in LDCs. There is an urgent need to add the more recently actual development of new products. Yet it is unlikely that
developed vaccines, such as pneumococcal, rotavirus and Hib adequate funding will be available to simultaneously support both
vaccines, to the LDC armamentarium. At the same time, we must new product development and vaccine purchase at today’s level.
realize that continuing high rates of disease that are preventable by On the other hand, national governments in some areas are now
older vaccines for measles, pertussis and tetanus, point to unac- fully capable of purchasing some of the well tested, lower priced
ceptable weaknesses in our existing delivery programs (Fig. 5). vaccines. Despite many of these purchases being funded by inter-
Lessons learned from countries that have high rates of vaccine national organizations today, some of the costs will have to be
coverage need to be translated to areas where the success has not taken over by national governments if newer vaccines are to be
be so great. Then all areas need the resources, infrastructure and moved along the development pipeline.
leadership to be enlarged to take on the new life-saving products All in all, the recent decades have been exciting. And the coming
that will continue to emerge from the development pipeline. years, with all of the attention, progress and financial support
Another structural challenge involves the building of organiza- coming to newer and better products and delivery systems, the field
tions that can guide the future development of vaccines for LDCs. will continue to deliver more and better products that will markedly
With the skills of vaccine development primarily residing in the improve the health of the world’s children at very reasonable cost.
private sector, finding experienced people to join not-for-profits
will continue to be a challenge. Moreover, many of the current
References
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[6] H. Greenberg. Personal Communication. 2008.
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Please cite this article in press as: Francis DP, Successes and failures: Worldwide vaccine development and application, Biologicals (2010),
doi:10.1016/j.biologicals.2010.06.003