A new vaccine against malaria – which kills 600,000 people every year, mostly children – will be injected into the arms of babies in 18 countries where the disease is deadliest. That is joyful news. But the unbridled enthusiasm that the announcement has generated says as much about the dire state of malaria control as it does about the brilliance of scientific invention.
Because this is an imperfect vaccine that will, at best, protect 75% of those who receive it. That is the highest figure from the clinical studies. In the reality of village life in poverty-stricken parts of Africa, less than half may be safe. It is still hugely important to get vaccination programs going in the 18 countries that will now be funded to carry them out, because many deaths will be averted. But it is not the end of malaria. Not around.
The R21/Matrix-M vaccine from the University of Oxford and the Serum Institute of India, which conducted the trials and will produce it, is the second vaccine to be sent into the field. The first was RTS,S – trade name Mosquirix – made by GlaxoSmithKline. It was founded in 1987 and then tried and tested in Ghana, Kenya and Malawi in 2019.
There is little difference between the outcomes of the two vaccines, which are designed and made in very similar ways. We’re not looking at a breakthrough mRNA vaccine here, using brand new technology as involved in the Pfizer/BioNTech and the Moderna Covid vaccines – although there are groups working on the early development of one.
The big difference is the price and the offer. There are alone 18 million doses of RTS,S available. The Serum Institute has committed to making this 100 million doses of the Oxford vaccine and double that the following year. The price will also be a lot lower – in line with other childhood vaccines generally used in Africa.
That’s really the good news. You can’t use a vaccine to save lives if you can’t afford or obtain it. The comments from Dr. Matshidiso Moeti, WHO Regional Director for Africa, were telling.
“This second vaccine has real potential to close the huge gap between supply and demand,” she said after the WHO announced its approval. Malaria is the disease that families in endemic areas fear. They want a vaccine. They have seen too many children get sick and die. Gavi, the Vaccine Alliance, will now raise the money to market the vaccine as widely as possible. That’s as it should be.
But this is not a one-time vaccine. It’s four shots. And because the vaccine works best in smaller babies, the first three vaccinations will be given at monthly intervals starting at five months of age, followed by a booster at two years of age, which will not coincide with the routine immunization schedule for children.
Families may need to travel to clinics, take a break from the field or work hard at home, and may need to bring other children along as well. Even in wealthy countries, children are not always brought back for a second vaccine dose. Professor Nick White of Thailand’s Mahidol University and Oxford, one of the world’s leading malaria experts, said malaria in Africa is linked to wars. In conflict areas such as the Democratic Republic of Congo, immunization is often a casualty. “Large parts of Africa will not be able to receive this,” he said.
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No one is pretending that the vaccine alone is enough. It should be used in combination with other measures, such as insecticide-impregnated mosquito nets. And it is crucial that clinics have the gold standard malaria treatment for those showing symptoms. These are the combination medicines with artemisinin that work very well until the malaria parasites, which are transmitted to a child through a mosquito bite, become resistant to them.
White believes that eradication of seasonal malaria should be the goal wherever possible. The two vaccines play a role in this and are given to the village population together with artemisinin medicines as a prevention of malaria infection, rather than as a cure.
The number of malaria cases has increased rather than decreased in recent years, much to everyone’s dismay. The climate crisis, conflict and drug resistance may all have played a role. But there is also fatigue among those fighting the battle, as one technology after another fails to deliver a killing blow. The Gates Foundation, after many years of major investments in the Mosquirix vaccine, stopped funding it in favor of other preventive measures, such as better mosquito nets. In July 2022, Philip Welkhoff, director of malaria programs at the Gates Foundation, told AP that the vaccine had “much lower efficacy than we would like,” and said they had to make tough decisions about its cost-effectiveness.
Funding has generally been a struggle, as there are no clear gains to be made on malaria. The approval and funding of the Oxford/Serum Institute vaccine could have an added benefit in boosting morale and hopefully generating more money and enthusiasm for the fight. It’s not a game changer, but it’s another real step in the right direction.