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Immunisation against one of the world’s deadliest killers could finally become a reality – if funders don’t fail the developing world again 

Lost among the front-page headlines about Omicron variants and monkeypox was the groundbreaking news that a vaccine for malaria may have been discovered. Malaria has often escaped the headlines because it's most heavily concentrated in sub-Saharan Africa and has been around for so long. Also, many people believe, incorrectly, that a cure has already been found. In fact, malaria has proven to be a consistently more lethal killer than most diseases, and news that it may have finally met its match in a vaccine known as R21 is reason indeed for celebration.

The vaccine's co-creator, Professor Adrian Hill, director of Oxford University's Jenner Institute, called R21 "the best (malaria) vaccine yet". He based his assertion on test results from Burkina Faso, which showed R21 to be 77% effective after the initial doses, which it maintained after a booster jab, and offered up to 80% protection in children aged five to 17 months. The Serum Institute of India has agreed to produce 200 million doses annually starting in 2023.

What is malaria's worldwide impact?

According to the CDC, there were an estimated 241 million malaria cases worldwide in 2020 and 627,000 people died of the disease, most of whom were young children in sub-Saharan Africa. That large number comes after a decade (2010-2020) of efforts to control the disease that cut malaria's mortality rate by 36%. 

The 87 countries at risk of malaria transmission represent almost half the world's population.

Young children are most vulnerable because they have not yet developed immunity to the disease. Pregnant women are also at an elevated risk because their immune systems are compromised during pregnancy. In addition, travellers and migrants from areas with little or no malaria transmission (Europe, Latin America, and Asia), are also exposed, lacking immunity.

In addition to the physical toll of the disease, the financial toll on families, paying for medical care, travelling to and from medical facilities, and burial expenses are considerable. Direct costs, such as illness, treatment and premature death, are estimated to be around $12 billion per year. That number, however, is dwarfed by the economic costs of the disease: some researchers believe it is reduces growth by 1.3% annually in certain African countries.

Why has it been so difficult to develop a malaria vaccine?

The speed with which a Covid-19 vaccine was created shows us what great minds, if they are well-resourced, are capable of. That's not to say that all viruses and diseases are created equal. They are not. However, researchers have known since the late 1990s that the core ingredient used in RTS,S, the last malaria vaccine breakthrough in 2021 that promised a 30% reduction in severe cases, would be effective. So why the delay? According to researchers, the reason was two-fold: firstly, the mosquito responsible for malaria, the genus Anopheles, transmits a particularly confounding parasite. Secondly, and most worrisome, was the chronic lack of urgency in treating the disease. 

The latter, rooted in racism, is saddening, considering malaria's staggering child mortality rate. "They're not Europeans, they're not Australians, they are poor African children," Ashley Birkett, director of the malaria vaccine initiative at PATH, a non-profit global health organisation, told Smithsonian. "Unfortunately, I think we have to accept that that is part of the reason for the lack of urgency in the community." It's sobering to think that the first secretive trials for a malaria vaccine took place in the 1940s.

When the US government asked Smith, Kline & French, a pharmaceutical giant that eventually became GlaxoSmithKline, to help find a vaccine in the 1980s to help overseas troops, they ran up against several medical obstacles. Primary were the different stages the parasite carrying the disease goes through once it was inside the human body. It is "actually changing clothes during the evolution, during the cycle," Lode Schuerman, the director of the scientific affairs for GSK's global health vaccines programme, told Smithsonian. The parasite’s ability to “dodge” the effects of any vaccine at least three times made it almost impossible to stop. 

But by 1998, a trial in Gambia for RTS,S yielded a breakthrough. Involving 250 men, it was found to be effective in 34% of infections. Despite the breakthrough, a limited commercial market in impoverished African countries delayed the development of a full vaccine. The Melinda and Bill Gates Foundation provided stopgap funding after the US Army pulled out, unconvinced about the success rate. 

After promising phase I and phase II trials, phase III trials funded by GSK ran from 2009 to 2014 in seven sub-Saharan African countries involving over 15,000 children. Complications with vaccinated children contracting meningitis and a higher death rate among vaccinated girls put a pause on trials and manufacturing. Four years later, another trial was eventually ready to launch, with 900,000 children in Ghana, Malawi and Kenya receiving the vaccine. In December 2021, GAVI, the global agency that funds and distributes vaccines in poor countries, announced an investment of $155.7 million to fund the RTS,S rollout. This occurred two decades after the first promising trials.

What are the plans for the R21 rollout?

The R21 rollout depends on additional funding from The Global Fund, an organisation coordinating efforts against Aids, tuberculosis and malaria. However, it has warned that it is currently underfunded itself and unless this changes, it will not have the necessary money. One of the major donors is the UK government, from whom the fund is thought to have requested $1.8 billion. In her previous role as foreign secretary, current UK prime minister Liz Truss outlined a significant retreat from funding for organisations such as The Global Fund.

"It's incredibly important that the Global Fund is properly refunded. What they do is absolutely amazing," Professor Hill, who also helped develop the AstraZeneca Covid vaccine, told the Guardian. "I hope the new prime minister will be very keen to recognise the importance of doing what the UK [the fund's third-biggest donor] has done so well in the past."

If The Global Fund resolves its finance issues and the rollout of R21 can proceed, following the results of a wider trial later this year and then manufacturing by the Serum Institute of India, the results could be truly groundbreaking: Professor Hill hopes that it may prevent as many as 70% of malaria deaths by 2030. The end of malaria's deadly reign in sub-Saharan Africa could finally be here.

Written by: Olivium staff.


NBC News: US troops and patients were used as malaria guinea pigs

Smithsonian: Why did it take 35 years to get a malaria vaccine?

The Guardian: New malaria vaccine comes a step closer as experts say ‘it’s the best yet’

Malaria Consortium: R21 malaria vaccine gives up to 80 percent protection

Reuters: Oxford malaria vaccine data bodes well for effort to combat deadly disease

CDC.gov: Anopheles Mosquitos

World Health Organization: World malaria report 2021

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