The trajectory of vaccine development in high‑income countries is approaching a turning point. With the licensure of respiratory syncytial virus (RSV) vaccines and monoclonal antibodies, most high‑incidence, high‑burden “low‑hanging fruit” for classical vaccine development and population‑wide recommendations have now been addressed. Pathogens for which routine vaccination might still be considered generally have annual incidences well below 50 per 100 000, too rare to generate a substantial public health impact. If tetanus were to emerge today as a novel threat, with historical incidences of roughly 1 in 250 000, it is doubtful that universal vaccination would be recommended; more likely, risk‑based strategies would be developed for narrowly defined groups such as military personnel or pregnant women and newborns in resource-poor settings. A similar situation already applies to meningococcal disease, where in many countries vaccine recommendations are restricted to specific risk groups or framed as “shared decision‑making” options, which in practice often means out‑of‑pocket...
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