The privilege and responsibility of having choices: decision-making for new vaccines in developing countries

Decisions to introduce new vaccines into national immunization programmes have become a highly complex endeavour. When the Expanded Programme on Immunization (EPI) was established in 1974 through a World Health Assembly resolution to build on the success of the global smallpox eradication programme and to ensure that all children in all countries benefit from life-saving vaccines, the first six diseases targeted by EPI were diphtheria, pertussis, tetanus, polio, measles and tuberculosis (WHO 1974). Today, thanks to scientific advancements and renewed global interest in immunization, more than a dozen antigens have been made available through public health services in developing countries, with increasingly reduced time delay compared with introduction in industrialized countries. Country decision-makers can select vaccines from a portfolio of options. This is a privilege and a serious responsibility requiring due consideration, as any decision to select one vaccine will need to be taken in light of the opportunity costs of not investing in another vaccine or another (health) intervention. Moreover, country decision-makers do not form their decisions in a vacuum; the number of immunization stakeholders in both the public and the private sectors has vastly increased and those stakeholders are equipped with varying levels of knowledge and expertise and may have vested interests. The multitude of factors influencing country decisions to introduce new vaccines, and the process for making these decisions is becoming increasingly important. These factors and processes are briefly outlined and discussed below.