A new vaccine against malaria – which kills 600,000 people every year, mostly children – is to be injected into babies’ arms in 18 countries where the disease is most deadly. That’s joyous news. But the unbridled enthusiasm the announcement has generated says as much about the sorry state of malaria control as the brilliance of scientific invention.
Because this is an imperfect vaccine that at best will protect 75% of those given it. That’s the top figure from the clinical trials. In the reality of village life in poverty-ridden parts of Africa, it may keep fewer than half safe. It’s still hugely important to get vaccination programmes going in the 18 countries that will now be funded to run them, because many deaths will be averted. But it’s not the end of malaria. Nowhere near.
The R21/Matrix-M vaccine from Oxford University and the Serum Institute of India, which ran the trials and will manufacture it, is the second to be dispatched into the field. The first was RTS,S – trade name Mosquirix – made by GlaxoSmithKline. It was created in 1987, then trialled and piloted in 2019 in Ghana, Kenya and Malawi.
There is little difference between the outcomes of the two vaccines, which are designed and made in a very similar way. We’re not looking at a breakthrough mRNA vaccine here, using brand new technology of the kind involved in the Pfizer/BioNTech and the Moderna Covid vaccines – although there are groups working on early-stage development of one.
The big difference is price and supply. There are only 18m doses of RTS,S available. The Serum Institute has undertaken to make 100m doses of the Oxford vaccine and double that in the following year. The price will also be a lot lower – in line with that of other childhood vaccines that are generally used across Africa.
That’s the really good news. You can’t use a vaccine to save lives if you can’t afford it or obtain it. The comment from Dr Matshidiso Moeti, WHO’s regional director for Africa, was telling.
“This second vaccine holds real potential to close the huge demand-and-supply gap,” she said after WHO announced its approval. Malaria is the disease families fear in endemic regions. They want a vaccine. They have seen too many children sicken and die. Gavi, the Vaccine Alliance, will now stump up the money to get the vaccine out as widely as possible. That’s as it should be.
But this is not a one-shot vaccine. It’s four shots. And because the vaccine works best in smaller babies, the first three shots will be given at monthly intervals, starting at five months old, followed by a booster at two years old, which will not coincide with the routine childhood immunisation schedule.
Families may have to travel to clinics, taking time out from the fields or hard work at home, perhaps bringing other children too. Even in affluent countries, children are not always brought back for second vaccine doses. Prof Nick White of Mahidol University in Thailand and Oxford, one of the world’s leading malaria experts, said that in Africa, malaria maps to its wars. In conflict zones such as the DRC, immunisation is often a casualty. “Large swathes of Africa will not be able to receive this,” he said.
Nobody is pretending the vaccine alone is enough. It has to be used in combination with other measures, such as insecticide-impregnated bednets. And it is vitally important that clinics have the gold-standard malaria treatment for those who show symptoms. Those are the artemisinin combination drugs that work really well until the malaria parasites, transmitted to a child in a mosquito bite, become resistant to them.
White believes the eradication of seasonal malaria should be the goal wherever possible. The two vaccines have a part to play in that, given to village populations together with artemisinin drugs as prevention of malaria infection, rather than cure.
Malaria cases have gone up rather than down in the past couple of years, to everyone’s dismay. The climate crisis, conflicts and drug resistance may all have played a part. But there has also been a weariness in those fighting the battle, as one technology after another fails to deliver a killer blow. The Gates Foundation, after many years of big investment in the Mosquirix vaccine, stopped funding it in favour of other preventive measures such as better bednets. In July 2022, Philip Welkhoff, the Gates Foundation’s director of malaria programmes, told AP that the vaccine had “a much lower efficacy than we would like”, and said they had to make hard decisions on cost-effectiveness.
Funding has generally been a struggle because there are no clear wins in malaria. The approval and funding of the Oxford/Serum Institute vaccine may have an additional benefit in boosting morale and hopefully leveraging more money and enthusiasm for the fight. It’s not a gamechanger, but it is another real step in the right direction.
