Sifting through the hype: the rollout of the first anti-malarial vaccine suggests a malaria-free Africa at hand

Analysis in brief: The rollout of the first vaccine approved to combat malaria will positively impact economic and societal change in Africa and end family tragedies for millions. While drug trials herald a medical breakthrough, health officials have been focused on results and not publicity.

The cost of malaria

For centuries, the development of Africa, particularly the central and southern regions, has been hampered by the prevalence of malaria, a disease more virulent in Africa than on any other continent. Africa is home to a particular type of mosquito, the Anopheles gambiae, which is extremely efficient at transmitting the parasite Plasmodium falciparum (the species that is most responsible for severe malaria and death) through skin bites to humans.

Because of Africa’s temperate and tropical climates, malaria transmission is not a seasonal but a year-round matter. Preventing and containing malaria is hindered by Africa’s lack of resources. Consequently, Africa carries a disproportionately high share of the global malaria cases. In 2022, Africa was home to 94% of the world’s malaria cases (233 million) and 95% of malaria deaths (580,000). Children under five are highly vulnerable to the disease, accounting for about 80% of all of Africa’s malaria deaths. However, the most vulnerable persons are those with no or little immunity against the disease. Africa has a high prevalence of people with immunities compromised by HIV and women whose immunities become compromised during pregnancy.

The economic cost to families is immense: purchase of drugs for treating malaria at home; travel expenses to clinics; lost pay due to absences from work; lost education due to absences from school; and ultimately, burial expenses when deaths occur. Countries’ public health systems are strained by the disease as they also deal with the cost of drugs, the provision and staffing of clinics, public health interventions against malaria (such as insecticide spraying or distribution of insecticide-treated bed nets) and lost tourism revenue in areas experiencing malaria outbreaks. Direct costs of malaria in terms of the effects of illness and premature death of individuals have been estimated to be at least US$12 billion per year. The cost of malaria on communities’ and nations’ economic growth is speculative but is considered to be even higher than the direct cost of malaria.

Africa’s climate is the primary reason the continent dominates the world’s malaria cases
Source: CDC, 2023

After successful vaccine tests, there is cause for optimism

The name RTS,S/AS01, a combination of letters, numbers and seemingly oddly placed punctuation marks, might appear more appropriate for a robot than a life-saving vaccine that is about to change the lives of a continent for the better. Unlike publicity that attended the promise of a potential AIDS vaccine, the introduction of this medicine was more subtle. In 2019, Ghana, Kenya and Malawi were selected for a pilot programme called the Malaria Vaccine Implementation Programme (MVIP), in which four doses of the medicine were given to residents aged five years and older in selected districts. Two million children were treated, and not only was a substantial reduction in malaria cases recorded, but the programme was also responsible for a 13% drop in mortality from all illnesses. The MVIP pilot programme also showed an ancillary benefit to the RTS,S/AS01 rollout: patients receiving the vaccine also took other preventative vaccines. This was the reason in a reduction in child mortality from all illnesses that was recorded during the programme.

The MVIP earned the World Health Organization (WHO) approval for RTS,S/AS01. On the evening of 21 November 2023, the first shipment of the vaccine intended for use by the general public (331,200 doses) arrived by plane at Yaoundé, Cameroon. The WHO then announced a full-scale malaria vaccination intervention had commenced across the highest-risk areas of the African continent. Soon following, 1.7 million doses of the vaccine arrived in Burkina Faso, Liberia, Niger and Sierra Leone. More African countries will receive the vaccine in 2024. Four African countries account for just over half of all malaria deaths worldwide (Nigeria has 26.8%, the Democratic Republic of Congo 12.3%, Uganda has 5.1% and Mozambique 4.2%). However, the selection of countries to receive the vaccine depended on the state of a country’s preparedness to incorporate an anti-malaria vaccine into that country’s current immunisation programme. In other words, vaccine distribution went to those countries where it would do the most good, where the health infrastructure could readily put it to immediate and effective use.

The Anopheles genus of mosquito carries the malaria-causing parasite, which is injected into the human bloodstream through the mosquito’s bite
Image courtesy: PICRYL

A golden bullet to be deployed with care

During the initial RTS,S/AS01 rollout to run through 2025, Benin, Burundi, Democratic Republic of Congo and Uganda will round out the 12 African countries that will be receiving the malaria vaccine, which include the three trial countries. Altogether, 18 million doses of this first-ever malaria vaccine will be distributed in an effort that has been well-planned and conducted with efficient co-ordination thus far.

However, cautious health officials and organisations are not relying solely on a vaccine to eradicate malaria in Africa. The WHO notes, “This vaccine has the potential to be very impactful in the fight against malaria, and when broadly deployed alongside other interventions, of saving tens of thousands of lives each year.” The interventions that will continue to be observed will be control measures that are now standardly subscribed for malaria-prone areas: insecticide-treated bed nets, indoor spraying and preventive treatment for pregnant women. These measures even without a vaccine have been responsible for the eradication of malaria in some locations and a significant reduction of malaria-related deaths throughout Africa since 2000.

Antimalarial drug resistance is another reason for health officials’ preference for caution over celebration with the vaccine rollout. Over the last decade, the WHO expressed concern over reports of patient resistance to the malaria treatment drug Artemisinin in Eritrea, Rwanda, Uganda and Tanzania. The monitoring of antimalarial drug efficacy is being stepped up to quickly detect and respond to drug resistance. These caveats aside, there is reason to find in the apparent success of the first anti-malaria vaccine a cheerful year’s-end story for 2023.

The critical points:

  • Africa is the continent most vulnerable to malaria and accounts for an overwhelming percentage of the world’s malaria cases and deaths, which for centuries have caused personal tragedy and economic damage
  • The first anti-malaria vaccine has successfully finished trials in three African countries, and full distribution is now underway in nine additional African countries
  • The full eradication of malaria also requires continued standard prevention measures like insect spraying and use of chemically treated bed netting