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- Celia Ford writes about what stands in the way of greater distribution of vital malaria vaccines.
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Malaria kills more than a thousand children every day. Measures like antimalarial medications and insecticide-treated bed nets, which stop infected mosquitoes from transmitting the disease-causing parasite to people while they sleep, have saved millions of lives at a relatively low cost. Yet despite these interventions, which reduced mortality by about 29 percent, over 430,000 children died from malaria last year. With the recent approval of two new malaria vaccines, RTS,S and R21, we have the opportunity to make another leap in the fight to eradicate malaria.
Malaria can be deadly for people of all ages, but it’s especially life-threatening for young kids: Over 75 percent of malaria deaths happen in children under 5. For now, malaria-endemic countries — like Cameroon, Burkina Faso, and the Democratic Republic of the Congo (DRC) — are focusing vaccination efforts on infants, who are already brought into clinics for routine shots anyway. Over the past year, 10.2 million doses were delivered to children across 17 countries. (So far, neither vaccine is approved for adults.)
The shots are largely paid for by Gavi, an international organization that uses donations from rich governments and philanthropies to subsidize lifesaving vaccine rollouts in countries with a gross national income per capita below $1,810 — about 2 percent that of the United States.
Last summer, Gavi announced its goal to raise $9 billion to fund immunizations from 2026 to 2030, with over $1.1 billion of those funds earmarked for new malaria vaccines. That’s enough to save around 180,000 children’s lives over the next five years.
But we could theoretically save many more.
A new paper by the Center for Global Development (CGD) estimates that 800,000 more child deaths could be avoided between now and 2030 — if Gavi buys and distributes as many vaccines as manufacturers can make. Though manufacturers say they have over 100 million doses ready to go, Gavi’s plan would buy only a fraction of them. To buy all of the currently available doses and put them into the field now, Gavi would need to triple its $1.4 billion malaria vaccine budget.
CGD’s proposed strategy — to buy and distribute as many doses as possible today, and trust that manufacturers will replenish their supply quickly — goes against conventional wisdom about vaccine rollouts. Gavi’s current strategy is to gradually ramp up R21 vaccinations, prioritizing the most vulnerable children first, while only distributing as many doses as can be stably purchased in the long run. By doing so, Gavi hopes to balance the urgent need to save lives with the importance of maintaining a sustainable vaccine supply. This is how most vaccines are introduced, including the first Covid vaccines in the US: quickly get them to the people who need them most, then ramp up to bigger populations slowly enough that suppliers can keep up.
Scott Gordon, head of Gavi’s malaria vaccine program, said that the success of a vaccine rollout largely depends on how ready a country is to get those shots into arms. Both available malaria vaccines require at least three doses to work, which means giving a person one shot isn’t enough. Clinics have to make sure people come back.
But other global health experts argue that now is the time for a more aggressive approach, to take advantage of the opportunity presented by these new vaccines.
“We suddenly have a tool where we can save lives at fairly low costs,” said Justin Sandefur, senior fellow at the Center for Global Development and co-author of its new paper. He argues that shying away from the most ambitious vaccine rollout possible costs too many lives to justify: “Logistically, bureaucratically, and politically, this is the kind of thing that we know how to do.”
Choosing the right vaccine will give countries more bang for their buck
The RTS,S and R21 vaccines are very biologically similar. Both vaccines target the same protein on the surface of malaria-causing parasites, teaching the body to attack the parasites before they make it to the liver and cause an infection.
The RTS,S vaccine, which was recommended for use by the World Health Organization in 2021, is about 56 percent effective — much better than nothing, but short of the WHO’s 75 percent target. Last December, the WHO also prequalified the R21 vaccine, which performed about 20 percent better at preventing severe malaria than RTS,S in its clinical trials. “Prequalification” is essentially approval: It means WHO believes R21 is safe, effective, and ready to be sold to UN agencies.
Effectiveness aside, R21 is much cheaper: $3.90 per dose, versus $10 per RTS,S dose. Because R21 particles are more densely packed with malaria protein antigens than RTS,S, a single dose of R21 can be much smaller than a single dose of RTS,S. Some other chemical differences also make R21 simpler to manufacture than RTS,S. As it currently stands, Serum Institute of India’s production capacity for R21 is nearly seven times greater than GSK’s production capacity for RTS,S. In fact, Serum Institute has already made 100 million doses, and it says it has the capacity to make even more.
So, R21 is more effective, much cheaper, and there’s loads more of it than RTS,S. 1Day Sooner, a nonprofit focused on high-impact infectious disease studies, argues that R21 should be rolled out as quickly as possible, in addition to RTS,S.
Read the full article about accelerating malaria vaccines by Celia Ford at Vox.