Many delegates attending a mid-March closed meeting led by the World Bank in Bellagio, Italy expressed emotions from disgust to amazement at what seemed to be the destruction of, rather than the transformation of, the Children's Vaccine Initiative (CVI). The meeting sounded the termination of the CVI, along with the contracts of its 14 staff by year's end and its replacement, at least in the short-term, by a much smaller secretariat acting purely as a clearinghouse of information between its partners—the World Bank, the World Health Organization (WHO), the Rockefeller Foundation and UNICEF.

The CVI, a nine-year-old multi-agency program, had been working towards the addition of new vaccines, such as hepatitis B, haemophylus influenzae B, rotavirus and the potentially new pneumococcal vaccines, to the existing world vaccination schedule (Nature Med. 4, 136; 1998). If delivered to 80 percent of the world's children, these four 'new' vaccines could save four million young lives each year.

Although many believe that shutting down this organization would be detrimental to global immunization programs, the Dean of Public Health at the University of Harvard, Barry Bloom—a passionate advocate for children's vaccines—says he is "thrilled" at the outcome. The Bill and Melinda Gates Children's Vaccine Program, founded in December last year with $100 million from the William Gates Foundation, is also clearly satisfied with the arrangement and has promised "a lot of program money" to develop a new initiative for improving the existing vaccination system.

Bloom's upbeat position is based on the argument that CVI has achieved its goal, and that its continued existence actually discourages its member organizations and associates from getting involved first-hand in new vaccine development and distribution. According to fans of the new deal, these organizations are now ready to make real commitments to buying and distributing new vaccines. The partners, including representatives from the pharmaceutical industry and donors but notably lacking delegates from countries needing the vaccines most, left Bellagio to forge a strategic plan to be ready by September. The goal is to achieve what they are calling "sunrise"—finally vaccinating the world's children with the new vaccines. A commitment to this objective is what thrilled Bloom.

However, some insiders believe that the dissolution of the CVI is a purely political maneuver. Under its new confident and technocratic leader, Grö Harlem Brundtland, the WHO is actively re-taking control of areas such as vaccine distribution, where its power had been slipping. "This is because WHO's capacity in immunization has grown tremendously in the time since CVI has been established," explains Bruce Ayleward, head of the WHO's polio eradication initiative, adding that "under the re-organization of WHO's activity here in Geneva, things have been changed."

And it seems that things are still changing at WHO headquarters, with internal rumblings over which cluster will gain ultimate control over vaccine programs: either the Health Technology and Drugs cluster, headed by Michael Scholtz, which currently oversees 90 percent of vaccine work, will retain control, or this will be passed to the Communicable Diseases cluster, headed by David Heymann. Likewise, it is also uncertain whether the new secretariat will be housed within the WHO or UNESCO.

WHO maintains that three objectives were agreed at the Bellagio meeting: to underpin the existing expanded program of immunization (EPI), which reached 80 percent of the world's children with six older vaccines in 1990; to finally eradicate polio, and use that and EPI as models of how to get new vaccines delivered; and for a group led by the World Bank to work on new financing mechanisms to raise the $2 billion budget needed for the program.

According to recent CVI estimates, $1–2 billion per annum is needed for the poorest countries. This breaks down into $100-200 million for immediate new vaccine purchases, an equal sum for infrastructure and rebuilding of a rotting cold-chain from airport to village; $500 million a year to purchase rotavirus and pneumococcal vaccines; plus a margin for unforeseen contingencies.

One major obstacle, however, is convincing partners such as industry that eliminating the neutral CVI is the right step. Alan Shaw, chair of the biologicals committee of the International Federation of Pharmaceutical Manufacturers Associations and head of vaccine research at Merck, admits that he was surprised by the outcome of the Bellagio meeting. "For the last 2–3 years the CVI had become a useful forum for discussions about vaccine policy and how to implement newer vaccines into the global immunization schedules. In a sense we were sorry to see that dismantled, but hope that we can build another means of doing the same thing," Shaw told Nature Medicine. Shaw is currently drafting a letter to be sent to Brundtland on industry's perceptions of the Bellagio meeting.

The pharmaceutical industry is particularly worried about the lack of independence of the new secretariat. Tom Vernon of Merck Vaccines wants to see some form of oversight group. "CVI not only advocated, it analyzed and criticized. Who will analyze and criticize "sunrise" and call partners to account if they fail in their commitments?" he asks.