Vaccines Can Finally Eradicate Malaria—But Not Without Support
The following op-ed by Claudette Wilson is one of five standout essays written as part of an assignment for the Columbia MPH Core and published online on the Columbia Mailman news page.
Malaria has plagued humanity from time immemorial. Cuneiform scripts on clay tablets from ancient Mesopotamia document fatal seasonal fevers, suggestive of malaria. Analysis of remains dating back to AD 450 provides evidence for a malaria epidemic in the ancient Roman Empire. Despite the devasting number of deaths malaria has caused since then, it has taken over a millennium to develop effective measures of protection against it. While the use of Insecticide Treated Nets (ITNs) and other vector control methods, as well as available medications, have significantly reduced the burden of malaria, elimination in areas where the disease is endemic has remained beyond reach, until now with the development of the first malaria vaccine. A targeted and aggressive distribution of the vaccine would finally ensure the elimination of this ever-present disease.
The malaria vaccine, RTS,S, is the first revolutionary response that might achieve what past eradication programs have failed to. Thirty years in development, the vaccine (administered over 4 doses) works to protect against malaria. However, since its approval for wide use by the WHO in 2021, only about 3 million vaccines have been distributed to populations at risk. The insufficiency of this number is better understood when compared to the distribution of COVID-19 vaccines, the first of which received approval only a few months earlier but reached an astounding 12.7 billion doses administered.
The WHO has adopted the approach of assimilating the vaccine into regular child immunizations through existing health systems. However, there is evidence that current population immunization compliance is sub-optimal and foreshadows the ineffectiveness of the proposed model for malaria vaccine distribution. A study conducted in 25 sub-Saharan countries estimated that, overall, 43.5 percent of children have either incomplete or no vaccinations with variations across countries and across SES. Another study identified and quantified the barriers to child immunization in Sub-Saharan Africa, listing limited access to healthcare and inadequate healthcare infrastructure to maintain vaccine supply and storage. That said, full RTS,S vaccine compliance will be improbable without auxiliary interventions that, while utilizing existing healthcare structures, are very targeted in mitigating the effects of existing structural barriers.
Funding should be channeled into strengthening aspects of healthcare systems associated with vaccine coverage and immunizations; namely, improvements in the supply and storage of the vaccine, hiring a sufficient healthcare workforce, equitably distributing vaccine access points, and creating a robust vaccine record database and technological means of informing and reminding parents to complete vaccinations. Global funding for efforts against malaria has stagnated and has fallen $2.3 billion short of the WHO annual funding target of $6.6 billion. Thus, it is imperative that available resources are applied towards more sustainable efforts than ITN distribution and seasonal home-spraying. Fortunately, vaccination has proven to be a relatively low-cost, high-impact intervention. The proposed funding streams would improve vaccine accessibility, bridge the gaps of inequality, and ensure higher rates of compliance with the full four-dose course of the RTS,S vaccine.
Moreover, the approach should emphasize community engagement to ensure community education and give space to voice their potential concerns. The aforementioned Sub-Saharan study also cited lack of knowledge and vaccine mistrust as barriers to child immunizations, so it is crucial that the population is educated through widespread media that teaches the efficacy and significance of the vaccine. Simultaneously, community outreach would address concerns understandably stemming from a history of unethical vaccine trial practices conducted in Africa. Concerted efforts by the government and community stakeholders would improve attitudes towards the vaccine; alleviating vaccine hesitancy and bolstering compliance.
On the other hand, the proposal for increased investment in the distribution of the RTS,S vaccine may be called into question given the vaccine’s mediocre efficacy rates of 39 percent in reducing the burden and fatalities of malaria in high areas of transmission. While it is reasonable to require justification for the cost of distribution, the vaccine’s benefits are far-reaching. Firstly, even though 39 percent efficacy seems low, there were 619,000 malaria deaths in 2021 alone and even a 39% reduction means that over 241,000 deaths would have been avoided. Additionally, more effective vaccines are under development, with one having been approved recently, and it is essential that effective distribution frameworks exist for them to make an even greater impact than the inaugural RTS,S vaccine. Finally, on a more pressing note, it is now crucial to increase our efforts against malaria and its transmission, as parasites are developing resistance to anti-malarial medication.
In conclusion, the development of the malaria vaccine has brought us to the cusp of potential malaria eradication. Each vial has the potential to reduce malaria severity, prevent hundreds of thousands of deaths annually, as well as ease the burden of malaria on the economies and health systems of countries.
We ought to publicize and distribute the vaccine like the transformative solution to malaria it is.
Claudette Wilson is a first-year MPH student in the Department of Health Policy and Management.