Africa needs malaria vaccines as soon as possible

A robust vaccine rollout is needed to save lives

This article is a departure from the normal Take Bakery column. After researching and learning about the topic, it became clear that this wasn’t something worth putting forth a half-baked idea on, so please enjoy this sincere article about the very serious problem of vaccinating the children who are most at risk from malaria.

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Malaria is one of the biggest killers in human history. Anthropologists have found evidence of the deadly disease afflicting the ancient Egyptians as far back as 3200 BC. Historians credit the spread of malaria, at least in part, with the demise of the Roman Empire and the decimation of British troops in Yorktown, which helped decide the American Revolution.

Today, 43 countries have completely or nearly eliminated malaria, but it still thrives in areas with poor public health resources and hot and humid climates. Nearly all of the 600,000 annual malaria deaths are in Africa, with half of them occurring in four sub-Saharan countries of Nigeria, the Democratic Republic of the Congo, Niger, and Tanzania. Children, who have significantly weaker immune systems, are especially vulnerable to the disease. Epidemiologists estimate that Plasmodium, the parasite transmitted through the female mosquito vector, has claimed the lives of 5 percent of the humans who’ve ever existed. Even today, it kills someone under the age of five every two minutes.

That’s why the date October 6, 2021 is a really big deal. It’s the day that the World Health Organization (WHO) approved the first malaria vaccine (RTS,S). Two years later, they approved another (R21).

After decades of research, we now have the scientific capability to significantly reduce the prevalence of one of the most deadly infectious diseases in human history. What we need now is a vaccine procurement and delivery process that matches the urgency of the moment.

Two life-saving vaccines

The RTS,S and R21 vaccines are quite similar. They both target the Plasmodium parasite before it infects the liver. They both require four separate doses, three over the initial several months along with a fourth booster several months later. They are both considered by the World Health Organization to be critical in the fight against Malaria.

In terms of vaccine efficacy, the current research shows that in regions with perennial malaria, the R21 vaccine will reduce disease contraction by 68% over a 12 month period. Comparatively, the RTS,S vaccine provides coverage at 56% in the same time-frame. While the clinical trials alone demonstrate that the R21 vaccine might be more effective than RTS,S, it's important to note that there has not been a head to head trial comparing the two vaccines. However, if both vaccines are deployed at scale, they have the potential to save tens of thousands of lives per year.

The most important difference between the two vaccines is in their production capacity. Currently, GlaxoSmithKline (GSK), the manufacturer of RTS,S, can only produce 18 million doses by 2025. In contrast, the Serum Institute of India, which manufactures the R21 vaccine, can produce 100 million doses annually by 2025. The R21 vaccine is also more affordable at $4 per dose compared to RTS,S at $10.

Eighty million children are eligible for the malaria vaccine, which will require the production, delivery, and administration of around 320 million doses across the continent over the coming years. This is an incredibly complex logistical task, but it's essential, as even with the advances of malaria prevention and treatment, the disease continues to kills a child every two minutes.

The vaccine supply gap

Currently, 25 million doses of the R21 vaccine are being delivered to Africa this year along with 6.6 million doses of GSK’s RTS,S vaccine. Gavi, the global vaccine alliance and UNICEF are primarily the organizations purchasing and distributing these critical vaccines at a cost that is a fraction of the market rate for each dose. Chad, Central African Republic, DR Congo, Mozambique and South Sudan are receiving the first vaccines now.

Obviously, the 25 million doses is well short of the 100 million that the Serum Institute can produce. Why are we not rolling out as many vaccines as possible to fight this incredibly deadly disease?

Zacharia Kafuko is a Zambian biochemist and director of the vaccine research organization 1Day Africa. He’s published two articles that raise questions about the gap between malaria’s vaccine production capacity and the supply to African countries.

In our conversation, he emphasized to me that Gavi is Africa’s most important player in the vaccine procurement process. “They have the money to buy vaccines for LMIC countries.” Moreover, because of Gavi’s “buying power, it’s able to get the best possible prices with suppliers or manufacturers.”

However, according to Kafuko, a problem is that Gavi is refusing to accept applications from countries who might want to switch from the RTS,S vaccine to the newly available R21 vaccine. Due to significant differences in supply, countries that are committed to the RTS,S vaccine before the R21's approval in late December will likely face longer wait times. Conversely, countries that opted for the newly released R21 vaccine might receive their supplies sooner.

I asked Gavi about this policy, and in a written statement, a spokesperson told me that “A key consideration is ensuring countries are able to scale up malaria vaccination programmes without switching products, which adds complexity, demands additional resources and investment, and can delay rollout.” However, the spokesperson added, that countries with “larger populations, who would need more volumes of malaria vaccine to scale up their programme, have already been matched with R21.”  

Importantly, the spokesperson also mentioned that due to capabilities in delivery capacity, they estimate the demand for malaria vaccines will be “40-60 million doses through 2026.”

Overall, there isn’t an obvious answer here. Gavi clearly understands the realities of vaccine demand and the logistics of supply. However, as Kafuko noted, African countries should have the autonomy to purchase the vaccines they need, even if they rely on Gavi's support to do so.

Getting shots into arms

It’s clear that the vaccine production and logistical supply system is complex. Producing, buying, and distributing the first-ever malaria vaccine to 80 million children across Africa will not be an easy task. However, in an interview with Time this Thursday, the CEO of the Serum Institute of India said, “We have the capacity, the demand, and the will of the people to want this vaccine, now we just need to get enough funding from Gavi [the vaccine alliance] and donors to be able to support that.’

Dr. Jaishree Raman, Principal Medical Scientist at the National Institute for Communicable Diseases, emphasized to me that the problem of cost really is a leading concern here. And that right now, it just isn’t cost-effective for Gavi and other organizations to be buying the vaccine at the scale in which it can be produced. A spokesperson for Gavi reaffirmed this to me, saying “It is accurate to say that we are moving from a supply constrained environment to a resource constrained one.”

Here, the COVID-19 vaccine deployment is an important point of comparison.

COVID-19 vaccines received an emergency use listing (EUL) during the pandemic, and in the years since, we’ve shipped over a billion vaccines to the continent. However, Dr. Raman says that’s largely because there was more demand for the vaccine that was driven by western countries, and the current urgency for malaria vaccines pales to what we saw during the COVID-19 pandemic.

The fight against Malaria is generally underfunded globally by several billion dollars annually, so it’s no surprise that the vaccine campaign is receiving a similar lack of attention. But there is precedent for a better globally funded vaccine campaign, and malaria certainly necessitates it.

Dr. Raman also highlighted the need for Africa to produce its own vaccines. Currently, Africa imports 99% of the vaccines it uses. One of the major issues with the current malaria vaccine is that it is produced in Europe and India. Building a domestic vaccine supply chain won’t just help support the fight against malaria, it will ensure that the continent is able to deliver life-saving vaccines in the future as well.

Importantly, Gavi has made an investment to boost the extremely nascent vaccine production sector in Africa. This effort will also be incredibly complex, and is also quite resource dependent. So more funding from private donors, wealthy countries (including in Africa), and support from international organizations is needed.

Again, there’s no clear solution here. But one of the most significant vaccine rollouts in recent memory is happening right now, and the extent of its success will determine the outcome of countless lives. It’s a mission that deserves more financial support, as well as more attention, especially from the places and people who are lucky enough to live far away from the scourge of malaria.