Will the Malaria vaccine be a game changer? Too early to call in Malawi.

by
Anopheles freeborni mosquito pumping blood.

Malaria is one of the world’s deadliest diseases. In Malawi, it is endemic across 95 percent of the country and is one of the leading causes of morbidity and mortality across all ages, and has a disproportionate impact on children under 5. In collaboration with many international partners such as the Centers for Disease Control and Prevention (CDC), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States Agency for International Development (USAID), and Gavi, the Vaccine Alliance, the Malawian Ministry of Health’s Malaria Control Program has been combating malaria for years by scaling up distribution of artemisinin-based combination therapies (ACTs), intermittent preventive treatment for pregnant women (IPTp) using sulfoxide-pyrimethamine (SP), and insecticide-treated net (ITNs) based on the World Health Organization’s (WHO) malaria guidelines and national level policies. But now, they may potentially have another tool to add to their existing package of services, a malaria vaccine!

Moms waiting for the malaria vaccine for their children in Malawi.

On April 23, 2019, Malawi, 1 of 3 countries selected for the Malaria Vaccine Implementation Programme (MVIP) pilot rolled out RTS,S/AS01 (RTS,S) – also known as Mosquirix , as part of their routine immunization for children under 5. It has been met with great excitement, as early speculation is that the vaccine could be a gamechanger in the fight against malaria. But there is still a way to go, four years to be exact after the completion of the pilot and research, before we know for sure. IF the pilot findings present positive results, i.e. higher levels of efficacy and effectiveness, does not have any severe adverse health effects, and can be incorporated into national immunization programs, then yes, we may have on our hands a new control to help reduce severe malaria morbidity and mortality in children under 5 in a significant way.

Now, despite my excitement regarding the potential impact RTS,S could have on malaria on childhood morbidity and mortality, it is too soon to tell. I am supportive of the vaccine pilot and the potential inclusion into policies and see the life changing benefits for patients, but with reservations. And, perhaps I am taking a more conservative stance based on my experience working and living in sub-Saharan Africa, seeing firsthand some of the systemic issues (i.e. lack of human resources, funding, poor infrastructure – in particular supply chain management, and government commitment) that continue to plague the efforts being made to improve health service delivery – all of which directly impacts routine immunization programs. That said, I’m eager to see what the pilot results yield, in particular as it relates to the economic and operational feasibility of implementation in low-income countries who are the hardest hit by malaria.

But while we wait, we must not lose track of continuing to implement existing prevention approaches and enforcing adherence to treatment guidelines, especially as we know malaria is on the rise again in Malawi, and around the world. There still needs to be significant increases of support and investment from cooperating governments and international stakeholders in improved surveillance systems and research on some of the challenges we’re encountering with existing methodologies, i.e. increased insecticide and anti-malarial drug resistance, and the biggest “unknown” of them all, how climate change will impact the mosquito burden and potentially increase the reach of this deadly disease globally.

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7 Responses to “Will the Malaria vaccine be a game changer? Too early to call in Malawi.”

  1. Jieming Chu Says:

    Hi, thanks a lot for sharing your insight. Recenty there have been many innovative attempts to address malaria, such as using lasers to zap mosquitos, using a gene drive to kill mosquitos that carry malaria and this vaccination effort. In my opinion the vaccination concept is perhaps the safest because the other two concepts could trigger unintended ecological problems if the mosquitos in question play other important roles in nature. I agree with you tha there should be more attention. Unfortunately, malaria is mostly a poor country’s problem and therefore has to rely almost entirely on government or non-profit funding to combat.

    • easelif Says:

      Thanks for your comments! And speaking of innovation … I just saw a billboard here in Uganda for mosquito killing paint made by Kansai Plascon! I’ll definitely be looking into that a bit more.

  2. nbmekonnen Says:

    Thanks for writing this blog post! I spent an additional hour just reading various articles on malaria in Malawi, specifically. I also agree that while it is great to have a vaccination, other known methods for prevention should continue, such as use of long-lasting insecticide nets, draining of sitting water, and more. I also found an interesting article (http://time.com/5577085/malawi-malaria-vaccine/) that states the vaccine is a pilot program and effective only 30% of the time. This is a stark difference to polio and other well-known vaccines that have an 80%+ effectiveness. In addition, this effectiveness was after receiving four doses, and it was known that the coverage wains with time (http://www.cidrap.umn.edu/news-perspective/2019/04/worlds-first-malaria-vaccine-program-launches-malawi). It will be interesting to see how, especially with the various limitations you have mentioned, this vaccine pilot will roll-out over the next few years and how they will manage multiple doses and use that data to improve beneficiary targeting and/or improve the vaccine. This is especially important because this partial coverage has taken 30 years and cost over $1billion dollars. I’ll be interested to keep up with this as it progresses; really interesting topic!

  3. lthomp63 Says:

    Hello! Thank you for writing on this topic! I was not up to date on the Malaria Vaccination project. It’s a very exciting prospect, and I know nations throughout the world are hoping to see this make a huge shift in the battle against malaria.
    Sub-saharan Africa is definitely known for its slow policy implementation and inconsistencies in support, but hopefully, the gravity of the situation will push stakeholders in to sustainable commitments.
    Thank you!

  4. dmannapova Says:

    @easelif: Was excited to read your post! Relating back to the introductory courses of the Global Health, I was reminded of how one of the lectures talked about decreasing trend of disease well before the invention/implementation of a vaccine. The case with malaria seems to be depended on factors that of its predecessors in global disease.

    It is also important for the stakeholders to not be swayed by the “cure-all” theory of a vaccine and understand it is a part of the solution. Therefore, to not replace old methods with the vaccine, but to re-develop the plan to incorporate the new method.

    Relating to a post I have written on HPV vaccination in Nepal and just like you have mentioned, there is a lot systemic issues that require a lot of effort, time and funding to make all the parts of the movement to work in order to eradicate malaria. Even with HPV vaccination that can prevent 70% of cervical cancer, number one leading cancer in women and leading cause of death in women from cancer in developing countries, there are plenty of systemic reasons as to why HPV vaccine is not part of National immunization Project.

    It is great to know that scientific research is always an ongoing portion of any epidemiological battle, even if it is done behind the curtain.

    @jiemingchu: If only I was able to be ignorant of the “butterfly effect” of mosquito extinction on ecological balance, then I would vote for that in a heartbeat!!!

  5. sarahskitchenweb Says:

    All ongoing efforts being made by many health agencies including the WHO’s malaria guidelines and national level policies, together with the envisaged new initiative of introducing malaria vaccines to fight one of the world’s deadliest diseases in Malawi is very encouraging, except for the side effects such as dizziness, depression, sleeping problems, experience of unusual dreams, fever, itchy rash, cough and loss of appetite that most malaria medicines such as Malarone dox dotes and vaccines like Mosquirix will cause in children under 5 years, despite the encouraging news that it might be a game changer in the fight against malaria per the 4-year pilot project.

    On the contrary, despite the envisaged higher levels of efficacy, effectiveness, and minimal severe side effects the Mosquirix vaccine brings and for that reason could be incorporated into Malawian national immunization programs to help reduce severe malaria morbidity and mortality in children under 5 in a significant way, all these efforts seem to be abrupt solutions which could be seen as instantaneous, but not actually grabbing the bull by the horn or addressing the actual root causes of mosquitoes infestation in that region. Factors such as stagnant water, wet mulch, shade, blocked drains, and others have been attributed to attracting mosquitoes in communities.

    While stagnant water like anything from a bucket of water or plant pot to pool or fountain that can turn into a breeding ground is the number-one factor, wet mulch along with other common yard decorations such as pine straw and wet soil in flower beds that can hold enough moisture below the surface to attract mosquitoes to lay eggs, shades and cool places preferably those with high moisture contents that could be habitats for mosquitoes, and blocked drains or drainage systems on or near communities that serve as invitation to treat for mosquitoes to hang around and lay eggs, and other factors have been identified as vibrant ways that mosquitoes breed and multiply, nothing is being done to address these root factors, making the proposed solutions with medications like “fetching water with baskets or strainers” which is ineffective.

    It would be very productive if money could be vested into addressing some prevention options afore-mentions root cause factors through educational campaign on sanitation and environmental cleanliness in those affected communities, like regular cleaning of larger bodies of waters, such as pools making sure that the filters work properly and installation of fountains to get the water circulating making it difficult for mosquitoes to breed in them, clearing and burning of mulches following weeds control to avoid mosquitoes making homes underneath those surfaces, creating open and dry spaces especially during warmer times of the day where mosquitoes can’t find any shady places to hide outdoors during the day like under decks and porches, as well as natural vegetation like untrimmed bushes, tall grass, and even low-hanging tree branches, and last but not the least, properly clearing gutters and drains by removing debris such as sticks and leaves out of any water drainage paths like trenches or open stormwater culverts to prevent any forms of stagnant water to cause breeding grounds for mosquitoes. When the discussed solutions above are addressed, underlying inputs of the health initiatives and policies by the WHO, this mosquito problem could be curtailed and reduced.

    In conclusion, as mentioned above, it is very encouraging and promising that the WHO’s initiative in introducing the RTS,S or Mosquirix vaccine to complement other solutions engineered by other health agencies to combat heavy malaria infestation that is endangering childhood morbidity and mortality, but then it is premature to weigh into its success due to prior efforts introduced by other health agencies that had not reduced or eliminated that problem. Once again, the Mosquirix vaccine pilot program isn’t a bad idea as long as its side effects do not outweigh its benefits in the life of targeted patients, thus, I am playing the devil’s advocate. Last but not the least, in addition to addressing the root cause factors discussed above, it is also urgent that systematic setbacks such as poor funding, inadequate local health service personnel, poor networking, appalling road infrastructure, ineffective supply chain management, and lack of government commitment be improved. No amount of health policies regardless of their effectiveness will be productive if the systematic setbacks and root cause factors of mosquito infestation are not addressed head-on. With that point made, let’s see how the implementation of the Mosquirix vaccine pilot program play in Malawi, so that whatever results are derived would be holistically evaluated by weighing the pros versus the cons to determine if the program was a success in making a positive impact in the lives of under 5 years children against malaria.

    Here are some links for further reading;

    https://www.bredapest.com/news/four-factors-that-increase-the-number-of

    https://medshadow.org/antimalarial-drugs/

    https://www.rxlist.com/malarone-side-effects-drug-center.htm#overview

    https://www.webmd.com/drugs/2/drug-19799/malarone-oral/details

  6. Will the Malaria vaccine be a game changer? Too early to call in Malawi | Tropical Health Matters Says:

    […] Fleming has recently posted a perspective on the new malaria vaccine intervention testing at “Social, Cultural & Behavioral Issues in PHC & Global Health.” See her observations below. Malaria is one of the world’s deadliest diseases. In Malawi, […]

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