Association of strategic management with vaccination in the terms of globalization.

Globalization is having an ever growing impact on the field of vaccine production and distribution in the world and domestically. In this article we examine the impact of taking a strategic approach to vaccination programmes by all the relevant actors: WHO, UNICEF, national immunization programmes, and vaccine manufacturers and distributors. The review of the relevant literature indicates that there are commonalities to the worldwide vaccination programmes. A comparative analysis of various vaccination strategies recommended by WHO and the immunization calendars of certain European countriesis made as well as an analysis of the Serbian vaccination programme. New and more expensive vaccines will continue to appear on the market in increasingly short periods of time.

WHO Expert Committee on Biological Standardization. Sixty-third report.

This report presents the recommendations of a WHO Expert Committee commissioned to coordinate activities leading to the adoption of international recommendations for the production and control of vaccines and other biologicals, and the establishment of international biological reference materials. Following a brief introduction, the report summarizes a number of general issues brought to the attention of the Committee. The next part of the report, of particular relevance to manufacturers and national regulatory authorities, outlines the discussions held on the development of revised WHO Recommendations and Guidelines for a number of vaccines, blood products and related substances. Specific discussion areas included the development of WHO guidance on the quality, safety and efficacy of poliomyelitis vaccines; recombinant malaria vaccines; diphtheria vaccines; tetanus vaccines; combined vaccines based on diphtheria and tetanus vaccines; and Japanese encephalitis vaccines. Subsequent sections of the report then provide information on the current status and proposed development of international reference materials in the areas of vaccines and related substances; blood products and related substances; in vitro diagnostic device reagents; biotherapeutics other than blood products; and antibiotics. A series of annexes are then presented which include an updated list of WHO Recommendations, Guidelines and other documents on biological substances used in medicine (Annex 1), followed by a series of WHO Recommendations and Guidelines adopted on the advice of the Committee (Annexes 2-7). All additions made during the meeting to the list of International Standards and Reference Reagents for biological substances maintained by WHO are then summarized in Annex 8, and are also available at: http://www. who.int/biologicals.

Risk perception, risk management and safety assessment: what can governments do to increase public confidence in their vaccine system?

For decades vaccine program managers and governments have devoted many resources to addressing public vaccine concerns, vaccine risk perception, risk management and safety assessment. Despite ever growing evidence that vaccines are safe and effective, public concerns continue. Education and evidence based scientific messages have not ended concerns. How can governments and programs more effectively address the public's vaccine concerns and increase confidence in the vaccine safety system? Vaccination hesitation has been attributed to concerns about vaccine safety, perceptions of high vaccine risks and low disease risk and consequences. Even when the public believes vaccines are important for protection many still have concerns about vaccine safety. This overview explores how heuristics affect public perception of vaccines and vaccine safety, how the public finds and uses vaccine information, and then proposes strategies for changes in the approach to vaccine safety communications. Facts and evidence confirming the safety of vaccines are not enough. Vaccine beliefs and behaviours must be shaped. This will require a shift in the what, when, how and why of vaccine risk and benefit communication content and practice. A change to a behavioural change strategy such as the WHO COMBI program that has been applied to disease eradication efforts is suggested.

Aluminum adjuvant dose guidelines in vaccine formulation for preclinical evaluations.

Aluminum (Al) salt-based adjuvants are present in a large variety of licensed vaccines and their use is widely considered for formulations in clinical trials. Although the regulatory agencies have clearly stated the acceptable levels of Al salts in vaccines for human use, there are no general indications for preclinical research. This brief commentary reviews the current status of Al concentrations in licensed vaccines, the related potential toxicity in preclinical species, and proposes a general guideline for selection of suitable Al salt levels in preclinical models, focusing on the formulation development for recombinant protein antigens. A table with conversion factors is included in order to provide a tool for calculation of doses with different Al salts.

Acceptable levels of endotoxin in vaccine formulations during preclinical research.

This brief commentary reviews endotoxin levels of commercial vaccines and puts them into context for the preclinical researcher working in vaccines. Vaccines are not required to adhere to endotoxin levels as outlined in the United States Pharmacopoeia. Vaccine manufacturers have to show that the vaccine is safe and efficacious in clinical trials. Endotoxin limits are typically lot release specifications for most vaccines, but these values are not available to most researchers designing preclinical experiments. The limits outlined are calculated from endotoxin levels found in a variety of vaccine types such as gene vectors, recombinant subunits, polysaccharide, live attenuated, inactivated and toxoid vaccines. It is clear that certain families of vaccines such as toxoids contain much higher levels of endotoxin, where others such as purified recombinant subunits and gene vectors may contain very low levels.

A new method for the evaluation of vaccine safety based on comprehensive gene expression analysis.

For the past 50 years, quality control and safety tests have been used to evaluate vaccine safety. However, conventional animal safety tests need to be improved in several aspects. For example, the number of test animals used needs to be reduced and the test period shortened. It is, therefore, necessary to develop a new vaccine evaluation system. In this review, we show that gene expression patterns are well correlated to biological responses in vaccinated rats. Our findings and methods using experimental biology and genome science provide an important means of assessment for vaccine toxicity.

Comparison of requirements in the European Union and United States of America for pre-clinical viral safety testing of veterinary vaccines.

Of paramount importance in ensuring the safety of live and inactivated veterinary vaccines is demonstration of freedom from extraneous agents in biological starting materials used in their production. Both the European Union (EU) and United States of America (US) provide regulations and guidelines on extraneous agent testing of veterinary vaccines including guidance from the Committee for Medicinal Products for Veterinary Use (CVMP), the European Pharmacopoeia (Ph. Eur.) and the USDA Code of Federal Regulations, Title 9 (9CFR). There are distinct requirements prescribed in EU and US regulations and guidelines. The differences in EU and US requirements for extraneous agent testing of starting materials are such that there may be occasions when no one test may satisfy both sets of regulations for a given scenario. For compliance with both, for global licensing purposes it may therefore be necessary to perform additional tests and/or to justify methods chosen from one set of regulations over another, based on a variety of factors.

Modern veterinary vaccines and the Shaman's apprentice.

This paper is an overview and assessment of new, commercially available veterinary vaccines placed in a historical context. The authors critically evaluate the current state of the field of veterinary vaccines in both food and companion animals and the promises for future vaccine development. The authors maintain that there is considerable variability in safety and sustained efficacy among veterinary vaccines, especially those developed for companion animals. It is proposed that establishment of an international vaccine advisory committee be supported which would function to apprise the veterinary profession of the current status of vaccines and their use.

Adjuvants designed for veterinary and human vaccines.

Adjuvants play an important role in the efficacy of vaccines as the antigens become more and more purified. Indeed recombinant proteins or synthetic peptides are safer than crude inactivated micro-organism, but less immunogenic. This can be balanced by specific adjuvants. But there is no universal adjuvants and their action is not yet clear and rely on different mechanisms. Then, they must be adapted according to several criteria, like the target species, the antigens, the type of immune response, the route of inoculation, or the duration of immunity. For this purpose different type of emulsions have been developed. Water in oil (W/O) emulsions induce a strong and long term immune response. Those based on mineral oils are known to be very efficient but can sometimes induce local reactions with reactive antigens. Non mineral oils are well tolerated but less efficient with poor immunogens. Multiphasic (W/O/W) emulsions can induce short and long term immune responses with various antigens and oil in water (O/W) emulsions are well tolerated and induce a short term immune response. New generation of adjuvants are based on a new concept called 'immunosol' and stem from the association of nanoparticles with a new immunostimulant. They can be used when emulsions are not suitable to obtain a good balance between safety and immunogenicity.

Current status and future trends in vaccine regulation--USA.

In regulating vaccines, the US Food and Drug Administration (FDA) is governed by the Code of Federal Regulations. These regulations serve as the framework for product characterization, as well as preclinical and clinical testing strategies. Novel vaccine approaches such as combination vaccines, vectored vaccines, new adjuvants, and novel delivery systems pose unique regulatory challenges for the FDA. If US licensure is sought, communication with the FDA throughout the clinical development of a product is essential to identify and implement the appropriate strategies for demonstrating the safety and effectiveness of a new product.

Ensuring vaccine safety in immunization programmes--a WHO perspective.

Ever since vaccines were firstly used against smallpox, adverse events following immunization have been reported. As immunization programmes expand to reach even the most remote communities in the poorest countries, it is likely that many more events will be temporally linked with vaccine administration. Furthermore, the profound shift in the general public and media interest in adverse events may lead to undue concerns and allegations which may ultimately jeopardize immunization programmes world-wide. While the health professional has understood this issue for some time, the public and the media have now also become all too aware of the significance of vaccine-related adverse events. The familiar vaccines, well-tested over decades, have not changed--but the perception regarding their safety has shifted. Claims outrageous or reasonable are being made against both the old and the newly-introduced vaccines. At the same time, the immunological and genetic revolution of the last decade may well bring to our notice some hypothetical risks that need to be addressed at pre-clinical level. WHO has been at the leading edge to guarantee vaccine safety for the last 30 years and will continue to do so. The Organization's plans for the next decade and beyond include the Safe Injection Global Network (SIGN), the development and introduction of safer technologies, and the prevention, early detection and management of AEFIs. The new technologies include needle-containing injection devices such as the autodisable syringe, as well as mucosal and transcutaneous immunization. Training will continue to be at the centre of WHO's efforts, limiting human error to a minimum. Mechanisms have been set in place to detect and respond to new and unforeseen events occurring. Above all, there is a willingness to respond to new climates and new technologies so that the Organization is in the best position to ensure safe immunization for all the world's children.

Standardisation of glutaraldehyde-modified tyrosine-adsorbed tree pollen vaccines containing the Th1-inducing adjuvant, monophosphoryl lipid A (MPL).

BACKGROUND: a new range of allergy vaccines has been developed by the introduction of a relatively new Th1-inducing adjuvant known as 3-deacylated monophosphoryl lipid A (MPL). MPL adjuvant is of natural origin, derived from the lipopolysaccharide of Salmonella minnesota R595. This adjuvant is incorporated in a glutaraldehyde-modified pollen extract adsorbed to L-tyrosine (Pollinex Quattro). A major potential benefit provided by MPL adjuvant is the promotion of a Th1 response which enhances the efficacy of allergy vaccination and can consequently allow a reduction in the number of injections required for treatment. The standardisation of Pollinex Quattro tree pollen allergy vaccine is described and we include details of some innovative analytical procedures. METHODS AND RESULTS: an essential feature of the analytical strategy is the assay of the MPL adjuvant using a recently developed HPLC technique. The adjuvant has a complex chemical structure and the analysis is illustrated in detail. We give a full picture of the vaccine standardisation by describing biochemical and immunological characterisation of the allergen extract, together with some brief manufacturing details. CONCLUSIONS: a high overall level of standardisation is illustrated by a number of different tests applied to all stages of vaccine manufacture. Tree pollen allergen potency is measured following the pollen extraction, chemical modification and formulation as a tyrosine adsorbate. Good batch-to-batch reproducibility is shown. The HPLC assay for MPL adjuvant showed high quality resolution which did not vary when measuring raw material or when incorporated in the vaccine and the technically complex assay is shown to be reliable.

Evaluación operativa de la cadena de frío de las vacunas / Operative evaluation of the chain of the cold of the vaccines

La calidad de las vacunas depende en gran parte de la conservación ininterrumpida a bajas temperaturas durante el proceso de distribución y almacenamiento de las mismas. Metodología: el presente trabajo se llevó a cabo en los centros de salud de la zona IV de Salud del Ministerio de Salud publica de Misiones Rep. Argentina. Se trata de un estudio cuasi experimental longitudinal, con un solo grupo. Se estudiaron las variables independientes: capacitación del personal a cargo de la vacunación y la supervision capacitante continua de enfermeria, en relación al cumplimiento de la cadena de frío de las vacunas.AU

Safety of immunization injections in Africa: not simply a problem of logistics.

In 1995, the WHO Regional Office for Africa launched a logistics project to address the four main areas of immunization logistics: the cold chain, transport, vaccine supply and quality, and the safety of injections in the countries of the region. The impact of this logistic approach on immunization injection safety was evaluated through surveys of injection procedures and an analysis of the injection materials (e.g. sterilizable or disposable syringes) chosen by the Expanded Programme on Immunization (EPI) and those actually seen to be used. Re-use of injection materials without sterilization, accidental needle-stick injuries among health care workers, and injection-related abscesses in patients were common in countries in the WHO African Region. Few health centres used time-steam saturation-temperature (TST) indicators to check the quality of sterilization and, in many centres, the injection equipment was boiled instead of being steam sterilized. Facilities for the proper disposal of used materials were rarely present. Although the official EPI choice was to use sterilizable equipment, use of a combination of sterilizable and disposable equipment was observed in the field. Unsafe injection practices in these countries were generally due to a failure to integrate nursing practices and public awareness with injection safety issues, and an absence of the influence of EPI managers on health care service delivery. Holistic rather than logistic approaches should be adopted to achieve safe injections in immunization, in the broader context of promoting safe vaccines and safety of all injections.

Vaccine stability in the context of vaccine delivery in a developing country: India.

Infant immunisation coverages of 80-85% have become sustainable throughout the developing world. The vaccine market is enormous in developing countries; in 1992, the total consumption of vaccine doses amounted to 2207 millions. There were only 127 million births, and the actual doses given to infants would have been fewer than 1000 million. This indicates huge wastage, which could be saved if vaccines were more stable at high temperatures and did not become contaminated. The vaccine delivery problems are compounded by the rural residence of the majority of the population and by the reliance on village health workers who are not the optimum health care providers. Under these circumstances, post-marketing epidemiological surveillance of vaccine-preventable diseases is absolutely necessary to monitor vaccine performance which is a function of the efficacy of the products and their potency when delivered.

Experience with veterinary vaccines in warm climates.

After a short description of the African laboratories manufacturing veterinary vaccines, the authors explain the main constraints for the use, in the field, of veterinary vaccines in warm climates. The need to respect the cold chain from the supplier of vaccines to the recipient animal is emphasised. In the Ivory Coast, during national vaccination campaigns, it has been proved that the quality of the rinderpest and contagious bovine pleuropneumonia vaccines is satisfactory when there is no disruption in the cold transport services. The data of this survey are exposed. In the framework of a project entitled "Thermostable rinderpest Vaccine, Transfer of Technology", a thermostable vaccine has been developed. It is manufactured in different African laboratories and integrated in some Pan African Rinderpest Campaign (PARC) vaccination programmes. On the other hand, the prospects offered by new thermotolerant attenuated vaccines against Newcastle disease are exposed. Finally, the authors present an outlook on the development of thermoresistant veterinary vaccines, such as those produced by genetic engineering, in particular with pox virus vectors.