tag:theconversation.com,2011:/au/topics/sadcmalaria-112491/articlesSADCmalaria – The Conversation2021-11-06T08:08:43Ztag:theconversation.com,2011:article/1710312021-11-06T08:08:43Z2021-11-06T08:08:43ZMalaria elimination in southern Africa? Possibly, but these gaps need attention<figure><img src="https://images.theconversation.com/files/430472/original/file-20211105-17-1r1whoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Blood feeding female malaria vector Anopheles arabiensis.</span> <span class="attribution"><span class="source">University of Pretoria Institute for Sustainable Malaria Control </span></span></figcaption></figure><p>Malaria is a risk to <a href="https://www.health.gov.za/wp-content/uploads/2020/11/media-statement-2020-sadc-malaria-day-commemoration.pdf">three quarters</a> of the population in the Southern African Development Community, a 16-member organisation that draws in countries across southern and eastern Africa.</p>
<p>Some countries in the region have set a target to eliminate the disease from as early as 2023 to 2030.</p>
<p>Though this won’t be simple, it can be done. It’s a race between changes in mosquitoes, the malaria parasite, and changes in what people can do when they work together.</p>
<p>This complex disease is still responsible for almost half a million deaths annually worldwide, including more than <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">260,000 African children</a> under five. The World Health Organization (WHO) <a href="https://www.health.gov.za/wp-content/uploads/2020/11/media-statement-2020-sadc-malaria-day-commemoration.pdf">estimates</a> that 35 million children under five and about 8.5 million pregnant women in the region are at risk. </p>
<p>The Southern African Development Community (SADC) renewed its malaria control efforts in 2009 by establishing the <a href="https://malariaelimination8.org/sites/default/files/publications/raman_et_al_eliminating_malaria_from_the_margins_of_transmission_in_southern_africa_through_the_elimination_8_initiative_trssa_2021.pdf">Elimination 8</a> initiative. This is a coalition of eight countries working together to curb the spread of the disease. Four of them – eSwatini, Botswana, Namibia and South Africa – are reporting very <a href="https://malariaelimination8.org/sites/default/files/publications/e8_annual_report_2020.pdf">low transmission</a>. The other four – Angola, Mozambique, Zambia and Zimbabwe – are <a href="https://malariaelimination8.org/sites/default/files/publications/e8_annual_report_2020.pdf">high-burden</a> countries.</p>
<p>Current control strategies mostly target the mosquito vector, which transmits the malaria-causing parasites to humans when feeding. Vector controls include indoor residual spraying and insecticide-treated bed nets. Resistance to insecticides and changes in mosquito biting behaviour are slowing down gains made in malaria control over the past decade. </p>
<p>In the Southern African Development Community region, malaria transmission dynamics remain highly interconnected. This is because countries share related populations, economies, ecologies and epidemiologies. </p>
<p>This interconnectedness is leading to the identification of new gaps and challenges. But it is also allowing innovative alternative and complementary strategies to be developed through research across disciplines – and through collaboration. </p>
<p>Our experience over the <a href="https://www.up.ac.za/media/shared/236/ZP_Resources/up-ismc_2019_case-study_sd-report.zp203457.pdf">past 10 years</a> includes collaborations across the sciences and social sciences. Our work addresses anything from vector and parasite control to capacity building and education. It’s testament that an <a href="https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-11-431">integrated approach</a> is needed to reach elimination. </p>
<h2>Latest breakthrough</h2>
<p>The most recent advance in the fight against malaria is the first ever vaccine (RTS,S/AS01). The WHO announced in <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">October 2021</a> that it had approved the vaccine for use in children living in moderate to high malaria transmission areas. </p>
<p>The vaccine brings <a href="https://theconversation.com/breakthrough-malaria-vaccine-offers-to-reinvigorate-the-fight-against-the-disease-169500">hope</a> to affected communities. It is a step toward malaria elimination.</p>
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Read more:
<a href="https://theconversation.com/malaria-vaccine-is-a-major-leap-forward-but-innovation-mustnt-stop-here-169639">Malaria vaccine is a major leap forward: but innovation mustn't stop here</a>
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<p>But it’s not a cure. And it has <a href="https://theconversation.com/malaria-vaccine-is-a-major-leap-forward-but-innovation-mustnt-stop-here-169639">limitations</a>: </p>
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<li><p>it is only effective in very young children (five to 17 months) </p></li>
<li><p>at least four doses (including a booster 18 months after the initial dose) are needed for optimal effect </p></li>
<li><p>it prevents severe disease but not necessarily infection </p></li>
<li><p>it is only effective against <a href="https://www.tandfonline.com/doi/pdf/10.1080/21645515.2019.1669415?needAccess=true"><em>Plasmodium falciparum</em></a> – one of five human malaria parasites.</p></li>
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<p>In spite of these limitations, the vaccine can contribute to making gains in malaria control again. The danger is that the vaccine announcement may lead to countries taking their eyes off the ball. This can’t happen. </p>
<p>Even with a vaccine in hand, there are some big gaps that need to be filled for the region, and the globe, to reach malaria elimination. </p>
<h2>Some of the gaps</h2>
<p>One such a gap is in human resources. In particular, leadership and management skills in national malaria control programmes. <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-018-2199-3#:%7E:text=Actions%20to%20expand%20training%20for,programs%20at%20the%20national%20level">Adequate training</a> is needed to address these capacity challenges. The Southern African Development Community region has not benefited from routine training offered to national malaria control programmes in west and east Africa. </p>
<p>To address this, the Gates Foundation is providing financial backing for a course to be developed and delivered by a <a href="https://www.up.ac.za/up-institute-for-sustainable-malaria-control/news/post_3029960-up-institute-for-sustainable-malaria-control-secures-a-gates-foundation-grant-to-build-capacity-in-africa">transdisciplinary team</a>. The course aims to provide people with the skills they need as leaders, managers, implementation scientists and facilitators that can develop and apply effective evidence-based elimination strategies. This is an exciting new collaboration that will involve the University of Pretoria’s <a href="https://www.gibs.co.za/Pages/default.aspx">Gordon Institute of Business Science (GIBS)</a> and the <a href="https://www.up.ac.za/albert-luthuli-leadership-institute">Albert Luthuli Leadership Institute</a>.</p>
<p>The course will also aim to get women into more senior positions on national malaria control programmes.</p>
<p>A second worrying gap relates to fighting growing resistance to antimalarial drugs. Malaria treatment is dependent on drugs that either prevent disease onset or treat infected patients and prevent death. But there’s evidence of increasing <a href="https://www.nature.com/articles/s41467-020-20629-8">parasite resistance</a> to antimalarial drugs. </p>
<p>Continuous discovery and development of innovative antimalarial drugs that target all forms of the parasite are needed. We are doing ground-breaking work in this area. For example, a consortium approach has made a <a href="https://www.up.ac.za/up-institute-for-sustainable-malaria-control/news/post_2945911-up-researchers-team-discovers-new-compounds-with-the-potential-to-eliminate-malaria">breakthrough discovery</a> and has led to exciting developments in the areas of <a href="https://www.nature.com/articles/s41467-020-20629-8">parasite transmission blocking</a>, where two potent chemical compounds showed activity against all parasite forms in a laboratory setting. Both compounds show potential as drug candidates for malaria treatment and transmission blocking. </p>
<p>Future antimalarial drugs like this will ultimately mean that the region can move from malaria control to elimination.</p>
<p>In addition, more sustainable vector control methods need to be developed to overcome insecticide resistance. </p>
<p>Our work across disciplines has shown how collaboration can produce tools and strategies to address this. For example, ongoing research have looked at innovative product development, including <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-015-1005-8">polyethylene wall linings</a>, and <a href="https://theconversation.com/scientists-design-a-novel-formula-that-repels-and-kills-mosquitoes-95323">new repellent formulations</a>. </p>
<p>There are also still gaps on the ground in how control strategies are rolled out. Many don’t have enough community buy-in. This is key to success. Communities must be aware of malaria research taking place to understand its purpose and benefits. And people need knowledge about the disease so they have the power to take responsibility for their own health. </p>
<p>A major – and important – gap is funding. The <a href="https://www.unhcr.org/4afac5629.pdf">malaria budget must increase</a> substantially to incorporate the human resources, technology and other resources needed to effectively reduce transmission and to reach elimination.</p><img src="https://counter.theconversation.com/content/171031/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The countries share related populations, economies, ecologies and epidemiologies. This interconnectedness highlights challenges and opportunities for more effective malaria control across the region.Taneshka Kruger, UP ISMC: Project Manager and Coordinator, University of PretoriaTiaan de Jager, Dean: Faculty of Health Sciences and Director: UP Institute for Sustainable Malaria Control, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1710272021-11-04T15:53:15Z2021-11-04T15:53:15ZThe seven steps South Africa is taking to get it closer to eliminating malaria<figure><img src="https://images.theconversation.com/files/430218/original/file-20211104-11504-ubo1nb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa offers free malaria testing and treatment to anyone entering the country along shared borders.</span> <span class="attribution"><span class="source">Jaishree Raman</span></span></figcaption></figure><p>There were <a href="https://www.isglobal.org/en_GB/-/la-crisis-de-covid-19-podria-duplicar-los-casos-de-malaria-en-el-africa-subsahariana">dire warnings</a> that malaria cases would surge across Africa after the World Health Organisation (WHO) <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020">declared</a> the COVID-19 outbreak as a global pandemic in early March 2020.</p>
<p>Many felt that the already overburdened healthcare systems would not be able to cope with increased patient loads. There was also concern that the pandemic would disrupt the delivery of essential malaria services. </p>
<p>Fortunately, these predictions have not fully materialised. Most malaria control programmes on the continent took action to keep delivering essential malaria services. </p>
<p>The South African malaria control programme, for one, found ways to keep its efforts at stopping transmission on track despite the threat from COVID-19. For example, it set up systems to <a href="http://www.samj.org.za/index.php/samj/article/view/13111">screen and test for COVID-19 and malaria</a> in malaria-risk areas. It also modified the training for indoor residual spraying to comply with COVID-19 regulations.</p>
<p>South Africa is aiming to eliminate malaria by 2023. The disease only occurs in certain areas of the South Africa. It is currently limited to the low altitude border regions of three provinces – KwaZulu-Natal, Mpumalanga and Limpopo. KwaZulu-Natal is the province closest to eliminating malaria by 2023. And it’s closely followed by Mpumalanga. Unfortunately, Limpopo will most likely miss the 2023 elimination target. It is the province most affected by malaria. </p>
<p>In June 2021 China became the 40th country to be declared <a href="https://www.who.int/teams/global-malaria-programme/elimination/countries-and-territories-certified-malaria-free-by-who">malaria-free</a> by the WHO. Other countries to achieve this recently are El Salvador in 2021 and Algeria and Argentina in 2019. </p>
<p>South Africa has adopted a number of innovations to achieve its elimination goal. Seven stand out. These are: prompt diagnosis; reporting every confirmed case to healthcare authorities; effective treatment; effective vector control measures; monitoring resistance to antimalarials and insecticide; and increased community-based malaria testing and treating. </p>
<p>Most important has been the <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-021-03875-z">uninterrupted domestic funding</a> of the malaria elimination programme. </p>
<h2>One step at a time</h2>
<p>Malaria prevalence is low in South Africa. This is why diagnosis is key. Every malaria infection must be confirmed either by the microscopic examination of a blood smear or by a malaria rapid diagnostic test before treatment can be prescribed.</p>
<p>Treating a patient based only symptoms such as fever, fatigue and headache is not encouraged. Many other disease share these symptoms – including COVID-19. </p>
<p>All malaria-related healthcare professionals are allowed to use a malaria rapid diagnostic test to test for malaria within communities.</p>
<p>Notification after diagnosis is also important. Malaria is classified as a Category 1 medical condition in South Africa. This means that healthcare professionals must report every confirmed malaria case within 24 hours using the National Medical Conditions reporting system. </p>
<p>The prompt reporting of every case allows the malaria control programmes to investigate the case and respond in a timely manner to prevent further transmission or a malaria outbreak.</p>
<p>The next crucial step is treatment. South Africa was one of the first African malaria-endemic countries to use an artemisinin-based combination therapy. This treatment is recommended by the WHO for uncomplicated malaria. The drug used in South Africa (artemether-lumefantrine) is very effective. It has played a significant role in decreasing the country’s malaria burden. To ensure the drug remains effective, it is essential that all six doses of the drug are taken with some fatty food.</p>
<p>But medical interventions only go so far. Effective vector control is essential for malaria control and elimination. </p>
<p>Indoor residual spraying was developed in South Africa in the 1940s. This involves treating the inner walls of homesteads with an insecticide. It remains the primary method used to control the malaria mosquito in South Africa. But additional vector control tools are needed to achieve malaria elimination. </p>
<p>The national control programme is working with research partner organisations to test more tools. These include larviciding (treating mosquito breeding sites with chemicals or biological agents that kill mosquito larvae), and <a href="https://www.dst.gov.za/index.php/media-room/latest-news/2662-sterile-insect-technique-field-trials-to-eliminate-malaria-under-way">the sterile insect technique</a>. </p>
<p>Innovation is key to staying ahead of this disease given the threat of resistance. In 1999-2000 South Africa experienced a malaria outbreak. It was driven by the emergence of drug-resistant parasites and insecticide-resistant mosquito vectors. To prevent this from happening again, antimalarial drug and insecticide efficacy are routinely monitored by the national malaria control programme with support from partners. </p>
<p>Resistance to artemisinin-based combination therapy is emerging in some African countries. But artemether-lumefantrine remains effective in South Africa.</p>
<p>Lastly, the country has remained steadfast in funding its malaria control programme. The South African Malaria Control Programme is one of the few on the continent that is entirely funded by government. This stable source of funding has allowed the programme to carry out uninterrupted malaria control interventions.</p>
<h2>The final push</h2>
<p>These interventions have played a major role in getting South Africa close to eliminating malaria. But more work remains to be done. </p>
<p>The importation of malaria from neighbouring countries poses a significant threat to South Africa’s elimination aspirations. To address this problem South Africa, with support from a non-governmental organisation, <a href="https://www.humana.org/">Humana People to People</a>, has established malaria surveillance units. These are at strategic points along shared borders. The units offer free malaria testing and treatment services to anyone entering South Africa. </p>
<p>All individuals found to be have malaria are treated. They receive artemether-lumefantrine and a single low dose of transmission blocking drug, primaquine. These units have contributed to a significant decrease in malaria cases reported from the border areas.</p>
<p>Communities in malaria-endemic areas need to play an active role in eliminating malaria. They can remove potential breeding sites, ensure they get promptly tested for malaria when they have symptoms, and finish the entire course of antimalarials.</p><img src="https://counter.theconversation.com/content/171027/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaishree Raman receives funding from the National Research Foundation of South Africa, the National Health Laboratory Services Research Trust and the Bill and Melinda Gates Foundation. She is affiliated with Centre for Emerging Zoonotic Diseases, National Institute for Communicable Diseases, the Wits Research for Malaria, University of Witwatersrand and the UP Institute for Sustainable Malaria Control, University of Pretoria.</span></em></p><p class="fine-print"><em><span>Shüné Oliver receives funding from the National Research Foundation of South Africa and the National Health Laboratory Services Services Research Trust. She is affiliated with Centre for Emerging Zoonotic Diseases, National Institute for Communicable Diseases and the Wits Research for Malaria, University of Witwatersrand</span></em></p>The South African Malaria Control Programme is one of the few on the continent that is entirely funded by government. The stable source of funding has allowed for steady malaria control interventions.Jaishree Raman, Principal Medical Scientis and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesShüné Oliver, medical scientist , National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1696392021-10-11T15:06:13Z2021-10-11T15:06:13ZMalaria vaccine is a major leap forward: but innovation mustn’t stop here<figure><img src="https://images.theconversation.com/files/425668/original/file-20211011-18-73vdg2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A health worker prepares a malaria vaccination in Yala, Kenya</span> <span class="attribution"><span class="source">Brian Ongoro / AFP via Getty Images</span></span></figcaption></figure><p>The World Health Organisation (WHO) took an historic step in the fight against malaria when it recently recommended the use of a <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">malaria vaccine</a> for young children. The announcement marked a major achievement – the development of the first ever successful malaria vaccine against <em>falciparum</em> malaria, the deadliest form of malaria and the one that is most common in sub-Saharan Africa.</p>
<p>The wide uptake of the vaccine could prevent thousands of deaths in the region. According to the <a href="https://www.who.int/publications/i/item/9789240015791">2020 World Malaria Report</a>, over 250,000 children under the age of five years died of malaria in Africa in 2019. That is a very sombre statistic for a treatable and preventable disease.</p>
<p>The development of the vaccine (called RTS,S) has taken <a href="https://www.malariavaccine.org/sites/mvi/files/content/page/files/PATH_MVI_RTSS_Fact%20sheet_042019.pdf">over 30 years</a>. It is the culmination of work by researchers from the Walter Reed Army Institute of Research, in partnership with the pharmaceutical company GlaxoSmithKline and the global health organisation PATH.</p>
<p>Producing an effective malaria vaccine has been challenging as the malaria parasite is able to hide from the human immune system. In addition, different forms of the malaria parasite infect the liver and red blood cells. </p>
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Read more:
<a href="https://theconversation.com/why-does-malaria-recur-how-pieces-of-the-puzzle-are-slowly-being-filled-in-108833">Why does malaria recur? How pieces of the puzzle are slowly being filled in</a>
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<p>Vaccine trials were started in 2019 in three <a href="https://www.who.int/docs/default-source/immunization/mvip/mvip-milestones-to-programme-development-final.pdf?sfvrsn=14768db0_4">African countries</a> – Ghana, Kenya and Malawi. The study showed that the RTS,S vaccine was safe in young children, that it reduced hospitalisation and death in vaccinated children by over <a href="https://www.lshtm.ac.uk/newsevents/news/2021/severe-malaria-among-young-african-children-dramatically-reduced-through">70%</a>, and that a successful malaria vaccination programme was possible in rural African settings. </p>
<p>The pilot study also showed that the vaccine was able to reach children who were not being protected by other methods like bed nets in the <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-on-who-recommendation-for-wider-use-of-the-rts-s-malaria-vaccine">study sites</a>. This provided additional support to the calls for the widespread use of the vaccine in malaria-affected areas.</p>
<p><a href="https://www.who.int/publications/i/item/9789240015791">Since 2015</a> malaria case numbers have been either flat or on the rise. This follows 15 years during which the numbers had been on the decline.</p>
<p>The addition of the RTS,S vaccine to the malaria control and elimination toolkit could get global efforts back on track. But it cannot be viewed as the silver bullet required to achieve malaria elimination. </p>
<h2>Not a complete solution</h2>
<p>The vaccine has several <a href="https://www.tandfonline.com/doi/pdf/10.1080/21645515.2019.1669415?needAccess=true">shortcomings</a>. </p>
<p>Firstly, in its current form it only works very effectively in very young children, aged between five and 17 months. These children must be given three vaccine doses, at least one month apart. A fourth booster dose is recommended at 18 months for the vaccine to work optimally.</p>
<p>This is makes running an effective vaccination programme very challenging. One possible solution is using community-based vaccination programmes to increase access and improve compliance.</p>
<p>In addition, although the vaccine prevents severe disease, it doesn’t necessarily prevent infection. This is similar to the <a href="https://www.who.int/news-room/feature-stories/detail/vaccine-efficacy-effectiveness-and-protection">COVID-19 vaccines</a>. </p>
<p>Thirdly, it’s only effective against one (<em>Plasmodium falciparum</em>) of the five human malaria parasites. </p>
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<a href="https://theconversation.com/breakthrough-malaria-vaccine-offers-to-reinvigorate-the-fight-against-the-disease-169500">Breakthrough malaria vaccine offers to reinvigorate the fight against the disease</a>
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<p>There are other concerns too. One is increased <a href="https://www.africaportal.org/features/myths-and-models-whats-driving-vaccine-hesitancy-in-africa-and-how-can-we-overcome-it/">vaccine hesitancy</a> across Africa.</p>
<p>There are also likely to be challenges in meeting the demand for vaccines, given the current focus on producing COVID-19 vaccines. </p>
<p>In light of these challenges, the RTS,S vaccine cannot replace existing effective interventions. These include indoor residual spraying and the use of insecticide treated bed nets. Instead, the vaccine must be used <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-on-who-recommendation-for-wider-use-of-the-rts-s-malaria-vaccine">alongside these</a> to break the malaria transmission cycle.</p>
<p>As the RTS,S vaccine is only effective in young children, it will only be used where they are at higher risk of infection than older children. Such conditions are generally found in <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">moderate to high transmission areas</a>. In these areas, frequent malaria infections result in older children developing partial immunity. </p>
<p>This immunity prevents children from showing the signs and symptoms of malaria. They become asymptomatic carriers of malaria. Many malaria-endemic African countries, including Botswana, Eswatini, Namibia and South Africa, have very low transmission intensities, so the population does not develop immunity against malaria. </p>
<p>Including the RTS,S vaccine in a childhood immunisation programme in these low transmission countries would not be cost-effective.</p>
<p>Despite the challenges associated with the RTS,S vaccine, its addition to the suite of malaria control interventions is a leap forward in the global fight against malaria. But vaccine innovation must not stop here. Efforts must be put into developing a vaccine that is effective in older children and adults, which requires only one dose and is effective against all human malarias.</p><img src="https://counter.theconversation.com/content/169639/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaishree Raman receives funding from the National Research Foundation of South Africa, the National Health Laboratory Services Research Trust and the Bill and Melinda Gates Foundation. She is affiliated with Centre for Emerging Zoonotic Diseases, National Institute for Communicable Diseases, the Wits Research for Malaria, University of Witwatersrand and the UP Institute for Sustainable Malaria Control, University of Pretoria.</span></em></p><p class="fine-print"><em><span>Shüné Oliver receives funding from the National Research Foundation of South Africa and the National Health Laboratory Services Services Research Trust. She is affiliated with Centre for Emerging Zoonotic Diseases, National Institute for Communicable Diseases and the Wits Research for Malaria, University of Witwatersrand</span></em></p>The successful development of an effective vaccine against the deadliest form of malaria that is most common in sub-Saharan Africa is indeed a major achievement.Jaishree Raman, Principal Medical Scientist and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesShüné Oliver, Medical scientist, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1695002021-10-08T05:49:56Z2021-10-08T05:49:56ZBreakthrough malaria vaccine offers to reinvigorate the fight against the disease<figure><img src="https://images.theconversation.com/files/425302/original/file-20211007-8006-x1dr4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The first ever malaria vaccine promises to bring the battle against infections back on track.</span> <span class="attribution"><span class="source">Photo Illustration by Rafael Henrique/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p><em>The World Health Organization has announced a historic move: it has <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">recommended</a> the widespread use of the first ever malaria vaccine. The recommendation is based on the results of an ongoing <a href="https://theconversation.com/malawi-is-testing-a-new-malaria-vaccine-but-its-still-early-days-116007">pilot programme</a> in Malawi, Ghana and Kenya. Malaria is a huge global health challenge, around 409,000 people died of malaria in 2019 alone. The WHO African region carries significant proportion of the malaria burden – <a href="https://reliefweb.int/report/world/message-who-regional-director-africa-dr-matshidiso-moeti-world-malaria-day-2021#:%7E:text=In%202019%2C%20the%20WHO%20African,%25%20and%20deaths%20by%2060%25.">94%</a> of all malaria cases and deaths occurred in the region. Children younger than five are the most vulnerable. Ina Skosana asked Eunice Anyango Owino to explain the development, and its significance.</em></p>
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<h2>It has taken 30 years. Why so long?</h2>
<p>The most significant reason is that the malaria parasite is very complex. It has <a href="https://theconversation.com/why-does-malaria-recur-how-pieces-of-the-puzzle-are-slowly-being-filled-in-108833">different stages</a>; some in the mosquito and some in the human. Thus, scientists had to pursue a diversity of approaches. </p>
<p>For example, in the human there are two stages. These are the:</p>
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<li><p>Pre-erythrocytic stages (sporozoite, or spore-like, stage). This is the period when the parasite’s sporozoite from a mosquito bite enters the blood stream and heads for the liver to mature and multiply after which they are then released.</p></li>
<li><p>The blood stage (Merozoite stage). This is when the parasite’s merozoites are released from the liver, and multiply in the red blood cells.</p></li>
</ul>
<p>So an effective vaccine against the first stage (pre-erythroctic stage) would be one that elicits an immune response that would either prevent infection of the liver cells or lead to destruction of the infected liver cells. </p>
<p>An effective vaccine for the second stage (blood stage) would be the one that does one of three things: elicits immune responses that prevent infection of red blood cells; decreases the number of parasites in the blood; reduces the severity of the disease by allowing the body to develop a natural immunity with little risk of getting ill.</p>
<p>Another option was to develop transmission blocking vaccines. An effective transmission blocking vaccine would induce antibodies that would block maturation of malaria parasites in mosquitoes that feed on vaccinated individuals.</p>
<p>Another factor that contributed to the delay is that scientists working on malaria vaccines in the early stages lacked an understanding of the specific immune responses associated with protection against the parasite. </p>
<p>Also, malaria parasites – such as <em>Plasmodium falciparum</em> – display a variety of antigens on their surfaces that help them escape the immune system and also render vaccines based on specific antigens less effective. </p>
<h2>Can you tell us more about the vaccine?</h2>
<p>The vaccine RTS,S, trade name <a href="https://www.ema.europa.eu/en/opinion-medicine-use-outside-EU/human/mosquirix">Mosquirx</a>, is given in four doses to children between the ages of 5 months and 17 months; the first 3 doses are given monthly with the first at 5 months and the third at 9 months. The fourth, which is a booster dose, is given at between 15 and 18 months. </p>
<p>The <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">efficacy</a> is about 40% against malaria cases and 30% against severe malaria. </p>
<p>No two vaccines or diseases are comparable. The WHO has set an efficacy level of 50% and above for most vaccines and most highly efficacious vaccines offer 75 % and above level of protection. For example, the COVID-19 vaccines based on messenger (m)RNA technology by Pfizer and Moderna offer well above 90% protection level. </p>
<p>The RTS,S vaccine targets the parasites before they infect liver cells; it targets the circumsprorozoite protein on <em>P.falciparum</em> sporozoites surface and is thus considered a pre-erythrocytic vaccine.</p>
<h2>What are the next steps?</h2>
<p>First, the WHO and the manufacturers of the vaccine GlaxoSmithKline will be rallying countries, particularly those with high malaria burdens, to adopt the vaccine as part of their National Malaria Control Strategies.</p>
<p>They will also be asking these countries to set aside funds.</p>
<p>They will also be involved in fundraising from the global health community or work with partners, for a broader roll out of the vaccine. </p>
<p>There should be equitable and long term access to the vaccine. The vaccine should also be cost effective.</p>
<p>The hope is that the WHO announcement will re-energise the race to find even more efficient vaccines against malaria. Current <a href="https://www.ox.ac.uk/news/2021-05-07-promising-malaria-vaccine-enters-final-stage-clinical-testing-west-africa">reports</a> by the Jenner Institute of Oxford University suggest that a malaria vaccine that might meet the WHO goal of 75% is under trial in Burkina Faso.</p>
<h2>What does this mean for malaria control in Africa?</h2>
<p>The vaccine is an additional tool to the malaria control tool kit. </p>
<p>The vaccine does not provide complete protection. And will be introduced as part of a tool kit geared to reducing malaria infections and reducing fatalities. Other measures include bed nets and indoor residual spraying. </p>
<p>Nevertheless the vaccine has a great potential to reduce death and illness in high burden areas in sub-Saharan Africa especially if used in combination with pre-existing malaria prevention methods. For example a study by the London School of Tropical Medicine reported a <a href="https://www.lshtm.ac.uk/newsevents/news/2021/severe-malaria-among-young-african-children-dramatically-reduced-through">70% reduction</a> in hospitalisations and death in children given the Mosquirx vaccine plus antimalarial drugs.</p>
<p>Malaria control had been stagnating in some African countries, with countries like Sudan and Eritrea seeing a significant resurgence in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6466923/">recent past</a>.</p>
<p>The vaccine will reinvigorate the fight against malaria. And it offers the promise of bringing it back on track.</p><img src="https://counter.theconversation.com/content/169500/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eunice Anyango Owino receives funding from the National Research Fund (NRF), Kenya.</span></em></p>The WHO and the manufacturers of the vaccine will be rallying countries, particularly those with high malaria burdens, to adopt the vaccine.Eunice Anyango Owino, Medical Entomologist at the School of Biological Sciences, University of NairobiLicensed as Creative Commons – attribution, no derivatives.