It all used to seem so simple with conjugate vaccines. You added them to your infant schedule and, faster than anyone had dared to hope, the disease more or less vanished.^1,2 Not only did immunisation protect against invasive disease but it reduced upper respiratory carriage rates too,³ so there was herd immunity. Even when odd, unexpected mixing problems cropped up out of the blue—like acellular pertussis and Haemophilus influenzae type b (Hib) combinations^4,5—it didn’t really seem to matter.⁶ In 1999 we watched as meningococcus group C (MenC) set off down the path to oblivion^7,8 previously trod by Hib in 1992.⁹

Then, suddenly, with the arrival of the new millennium, it began to get more complicated. With the MMR vaccine scare still buzzing in people’s heads and the schedule busier with the addition of MenC, the 7-valent pneumococcal conjugate vaccine turned up in 2001 with a central European licence and unassailable evidence showing that it prevents invasive pneumococcal disease¹⁰ leading to its general introduction in the USA in 2000. The way this vaccine arrived was in stark contrast to MenC—which was a programme driven by strategic thinking from within the UK Dept of Health¹¹ in which three manufacturer’s had responded to the call and an enthusiastic public waited impatiently for a partial solution to the problem of meningococcal disease which they knew of and dreaded. Here was a vaccine specifically developed by one manufacturer, who had, by a combination of luck and shrewd judgement, stolen the march on all other contenders, with the US market as their primary target. (The luck was that the conjugates in their vaccine turned out to be very immunogenic: the US Food and Drug Administration …