Book Review

The Grand Challenge for the Future: Vaccines for Poverty-Related Diseases from Bench to Field

N Engl J Med 2006; 354:651-652February 9, 2006

Article

The Grand Challenge for the Future: Vaccines for Poverty-Related Diseases from Bench to Field
(Birkhäuser Advances in Infectious Diseases.) Edited by Stefan H.E. Kaufmann and Paul-Henri Lambert. 290 pp. Basel, Switzerland, Birkhäuser Verlag, 2005. $119. ISBN: 3-7643-7175-7

Vaccines have been one of the great success stories in preventive medicine. Smallpox has been eradicated, polio has been eliminated from much of the world, and measles — which once killed several million children annually — has been markedly reduced. However, the burden of infectious diseases, particularly those that affect persons in the developing world, remains unacceptably high. In the cases of some infectious diseases, delivery of vaccines to target populations in developing countries has been suboptimal. In other cases, such as invasive pneumococcal disease, vaccines exist but have not yet made their way into immunization programs in developing countries. Finally, the resources needed to develop vaccines for the prevention of diseases that do not affect persons in the industrialized world have been insufficient.

The Grand Challenge for the Future focuses on vaccines and vaccination programs for the developing world. Most vaccinology books concentrate on specific vaccines against specific diseases. That is not the focus of this book, which instead brings together micro and macro views of the development of vaccines and issues involving the implementation of vaccination. The first three chapters describe the underpinnings of the development and use of vaccines. These include methods used to assess the economic and societal value of vaccines, an industry perspective on the hurdles faced, and potential interventions the industrialized world could undertake to facilitate vaccination. Local manufacture is one means of reducing the cost of existing and new vaccines for developing countries, but there are multiple obstacles to overcome. One chapter of the book discusses ways of resolving these problems.

The three chapters of the “Bench” section of the book have relevance to both the developing world and the developed world. Among the topics addressed are new techniques to develop vaccines. For example, computer analysis of an organism's genome can be used to predict potential protective antigens. Adjuvants may enhance immunogenicity and reduce the quantities of vaccine antigens needed. Overcoming immunologic immaturity may be critically important; inducing an immune response at the earliest possible age would be crucial for the prevention of many diseases in developing countries, because exposure is common in early infancy, and vaccine-delivery programs tend to focus on the first year of life.

The chapter on regulatory issues lays out many of the steps that must be addressed in gaining approval for a vaccine. However, there is inadequate coverage of the special regulatory problems that are faced in developing countries, which often lack the resources to test and license vaccines. Clinical trials of vaccines in developing countries are complicated because critical research infrastructure may be lacking. Major ethical issues often arise when a vaccine that was developed in industrialized countries first is clinically tested in the populations of developing countries. The Grand Challenge for the Future offers suggestions for overcoming these hurdles. No discussion of vaccines is complete without consideration of vaccine safety, and this book offers a comprehensive discussion of safety evaluations and the development of safety monitoring systems.

After the development of vaccines comes their incorporation into routine immunization programs. Despite adequate financing of vaccines for many countries, vaccine-administration programs fail to reach target populations. Investments in health care delivery systems are essential if vaccines for the developing world are to achieve their optimal effect.

This book could have been improved by greater discussion of the implementation of immunization programs. Nevertheless, it is an excellent and comprehensive resource for scientists, the developers of vaccines, financiers, manufacturers, public health officials, and others interested in the prevention of infectious diseases in the developing world.

Walter A. Orenstein, M.D.
Emory University School of Medicine, Atlanta, GA 30322
worenst@emory.edu