The announcement that a malaria vaccine (1) has been approved for use in children has been met with huge excitement - and a bit of skepticism. In the main, this is a good story for the mother continent, which is, figures remind us, ground zero for malaria, particularly among children. Malaria remains one of the primary causes of childhood illness and death on this continent, killing over 250 000 children and toddlers annually. The vaccine could also not have come at a better time as a boost to the inoculation debate that’s raging across the planet because of the global Covid-19 vaccination rollout. When the World Health Organisation (WHO) recommended the widespread use of the malaria vaccine known as RTS,S, its head, Director-General Dr Tedros Adhanom Ghebreyesus, described this as a long awaited “breakthrough”. He said: “This is a historic moment. The long-awaited malaria vaccine for children is a breakthrough for science, child health and malaria control. Using this vaccine on top of existing tools to prevent malaria could save tens of thousands of young lives each year.” Amid the jubilation, though, questions are being asked about why it took so long to reach this point. Dr Matshidiso Moeti, the regional director of the WHO in Africa, said: “For centuries, malaria has stalked sub-Saharan Africa, causing immense personal suffering. We have long hoped for an effective malaria vaccine and now for the first time ever, we have such a vaccine recommended for widespread use. Today’s recommendation offers a glimmer of hope for the continent which shoulders the heaviest burden of the disease, and we expect many more African children to be protected from malaria and grow into healthy adults.” The deadly parasite malaria comes in the main via blood sucking mosquito bites; it destroys white blood cells, reproducing itself as it does so. A multi-pronged approach has been used over the years to prevent the disease from spreading. Bed-nets that protect children from being bitten while they are asleep, and insecticides designed to kill mosquitoes, are among the main prevention strategies. Despite these efforts, malaria cases remain alarmingly high. WHO stats report 229 million cases annually around the globe – 94% of those in Africa and a worldwide 409 000 death toll per year.
The RTS,S vaccine targets Plasmodium falciparum, the deadliest of all malaria-causing parasites (2) and the most prevalent in Africa. The WHO says the RTS,S vaccine will help 4 in 10 cases of malaria and 3 out of 10 in severe cases. Africans can be proud because the RTS,S vaccine is a result of more than 30 years of research and development by the pharmaceutical giant GlaxoSmithKline (GSK) as well as African research centres. The health ministries of Ghana, Kenya and Malawi, where 2,3 million doses have been administered, produced pilot data on the drug’s feasibility, safety and implementation. This was a global collaborative effort by the Vaccine Alliance, Unitaid, Gavi, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Bill and Melinda Gates Foundation provided catalytic funding at the critical late development stage between 2011 and 2015. WHO will lead the implementation programme together with international partners UNICEF, GSK and the three pilot in-country coordinators. The pharmaceutical giant has already donated more than 10 million doses. This is all good news, at first glance. But, as we have seen in recent months with Covid-19, the RTS,S rollout comes with its own set of complexities.
Pressure on health systems and budgets?
For instance, for the malaria vaccine to be deemed effective, it requires four doses (3). The first three doses need to be administered a month apart (when babies are 5, 6 and 7 months old); the fourth, a booster, is given at 18 months. This will certainly stretch African countries’ already fragile health systems infrastructure. And some are already pointed to constrained health budgets, worried that these will make such an extensive rollout difficult. At a potential cost of about $5 per dose, some researchers suggest the vaccine rollout, including its distribution, would cost around $325 million to administer each year across ten African countries with a high incidence of malaria. They point out that in some of these countries, other malaria measures have faltered because of a lack of support. A 2019 study concluded that around $630 million would be needed per annum to vaccinate 41 endemic countries in sub-Saharan Africa.
What are African researchers saying?
At Mali’s university of Bamako, malaria researcher Alassane Dicko said this about a discussion with the country’s health minister soon after the WHO’s announcement regarding the use of RTS,S: “I told her we need to push as a country, at the highest levels of our government, to make this vaccine available at an affordable cost as soon as possible,” he said. But not all the continent’s researchers are convinced. Badara Cisse, a researcher from the Institute for Health Research and Epidemiological Surveillance and Training in Senegal’s capital Dakar, expressed his concerns: “I respect the researchers involved with this massive effort, but the reality is that so much money has been poured into this vaccine, even when the results from studies are disappointing.” Also, in Cisse’s corner is a Ugandan epidemiologist at the Malaria Consortium in London, James Tibenderana. He said that the RTS,S vaccine could be impactful in some regions, but stressed the need for extensive mass communication campaigns, to prevent misinformation (4)from hindering the rollout. “People will wonder why a 30-year-old, partially effective vaccine is suddenly being introduced during a pandemic…. and targeted only at Africans.” Tibenderana warned: “The misinformation around Covid-19 vaccines should teach us that we can’t take community trust for granted.” However, he did acknowledge that in light of the devastation caused by Covid-19, “it’s uplifting to see some positive news”. Dr. Dorcas Wilson (5), a paediatric neurologist based in Johannesburg, South Africa, has seen children, mostly younger than five, suffering from cerebral malaria. She told Africa Asia Dialogues it is imperative that critical care reaches those who need it the most in the shortest possible time frames. That may mean vaccines need to be produced locally here in Africa. She said: “We welcome this breakthrough but in order for it to have a high impact on the ground, where most of these children are presenting in under-resourced hospitals, we may reach a stage, quite like the Covid-19 vaccine now being produced locally in Africa, also for the malaria vaccine production line to get closer to the people it is meant to serve.”
Fit for all?
The WHO itself has been criticised for taking a “one size fits all” approach. In a blog, the Center for Global Development (CGD) (6) said the WHO “should avoid issuing a sweeping global recommendation and encourage instead national and subnational assessments to inform decision-making processes”. “In short, any WHO policy recommendation concerning the implementation of new interventions for the prevention and treatment of malaria should consider value for money and sustainable financing as well as encourage countries to still conduct their own assessments and decide for themselves what is best for their populations. The best way to make progress is with firm, locally led steps,” the independent research and analysis centre added.
Better days ahead
Having suffered from the deadly disease myself, when I was bitten by a determined mosquito in South Sudan (pre-secession) and ended up in hospital for a couple of weeks with high fever and debilitating body aches, I can safely say this is a step in the right direction. However, as outlined above, there are many hurdles to overcome even at this euphoric moment. There are other vaccines that are still in pilot stage, like the Oxford vaccine (7) which is being piloted in Burkina Faso. Initial reports said it has a 73% efficacy, but a lot more work still needs to be done.
About the Author
Milton Nkosi Milton Nkosi is a chairman of MMN International Consulting, specialising in media, advisory and reputation. He is the former BBC News Africa Bureaux Chief and South Asia Bureaux Editor. He served as a trustee on the board of Warwick University's Warwick in Africa Programme.