Vaccine shortages eliminate possibility for excess capacity in stockpiles

The ability to provide vaccines to the entire population stands as one of the greatest achievements of the past century. Many new antigens have been developed, and now more antigens are offered as part of combination vaccines, reducing the number of injections. Vaccines that are routinely administered protect against 11 common childhood diseases. In addition, through herd immunity, immunization even offers some benefit to those who are not immunized. Providing additional protection has come at some additional cost, however. Immunizing a child with the 20 doses of recommended vaccines increased in price from 200 dollars to 400 dollars, (at the discounted government price) between 1997 and 2001. In spite of this impressive record, vaccines shortages have occurred for eight of the routinely recommended vaccines, and the conjugate pneumococcal vaccine is still in short supply, mandating deferral of doses three and four. These shortages have resulted in some harm to the system. Several temporary changes to recommendations were made, and it is not at all clear to what extent children for whom doses were deferred have been called back. School immunization requirements have been modified in 48% of states. Concern has been raised that we may see a reversal in the trend toward improved vaccine coverage, and the possibility of outbreaks is seen as very real. Some, but not all, of the immediate factors that led to the vaccine shortages of 2 years ago have been resolved. Longstanding factors that contributed to the shortages remain. Undervaluation by society, inadequate communication between involved parties, attrition of manufacturers, and the threat of frivolous litigation have not been addressed and may once again threaten the vaccine supply. Currently, four manufacturers are responsible for almost all of the routinely recommended vaccines used in this country. Five vaccines are produced by a single manufacturer. Only one vaccine, conjugate Haemophilus influenzae type b, is produced by three. It will take between 4 and 5 years to improve vaccine stockpiles to the desired levels. With fewer manufacturers, there is no possibility for "excess" capacity that may provide a cushion to augment stockpiles or address any unanticipated shortfalls in supply. In short, the potential for additional shortages remains substantial, and the ability to respond to shortages may actually have worsened. We must hope the return of widespread shortages or even outbreaks will not be necessary before real solutions are implemented.