Cameroon became the first country on Monday to roll out the World Health Organization’s first recommended malaria vaccine, RTS,S, into its routine immunization program. This means children visiting health facilities in the central African nation are the first to receive this ground-breaking vaccine outside of the pilot programs and clinical trials.
“We are not just witnessing, but actively participating, in a transformative chapter in Africa public health history,” Dr. Mohammed Abdulaziz, head of disease control and prevention at the Africa Centres for Disease Control and Prevention, said during a press briefing.
Africa carries the highest global burden of malaria deaths. There are about 580,000 deaths each year — and 80% of these are children under 5.
There are now two approved malaria vaccines. In 2021, the RTS,S vaccine was recommended for use by WHO — becoming the first vaccine developed against a parasite. Last year, WHO also recommended the use of a second malaria vaccine, R21, and pre-qualified it for procurement in December.
And so the rollout of the RTS,S has commenced, with the possible start of the rollout of R21 between May and June, said Aurélia Nguyen, chief program officer at Gavi, the Vaccine Alliance.
Cameroon will introduce the RTS,S vaccine in 42 districts where the population is most at risk for malaria, Nguyen said, adding that malaria cases and deaths have been rising in the country since 2017 with nearly 30% of all hospital consultations being malaria-related.
Twenty African countries plan to introduce malaria vaccines this year but the ability to hit that target depends, among other things, on how soon doses of R21 become available. Of these 20, seven plan to use RTS,S and eight plan to use R21 — for the remaining five, conversations are ongoing, a Gavi spokesperson told Devex.
Overall, more than 30 African countries have expressed interest in adding malaria vaccines to their routine immunization programs, Nguyen said.
For simplicity’s sake, countries will receive one of the two vaccines — but not both.
The development of RTS,S was decades in the making, which included clinical trials and then large-scale implementation programs in Ghana, Malawi, and Kenya — meaning the vaccine has already reached more than 2 million children.
The two malaria vaccines have been shown to reduce clinical malaria cases by more than half in the year after vaccination, with that level of efficacy increasing when the vaccine is provided seasonally — preventing about three-quarters of malaria cases, said Kate O’Brien, director of the department of immunization, vaccines and biologicals at WHO.
“If we think about the 250 million malaria cases that occur every year, a childhood vaccine with this level of efficacy can result in major reductions in malaria, illness, and death,” she said.
Experts at the press briefing emphasized that the vaccine is not a “silver bullet” and other interventions, primarily including bednets, are still necessary. There is no perfect tool for preventing malaria, they said, but each tool contributes to reducing incidence and mortality by a fraction.
“We won't see progress that we're hoping to get through the vaccine if we're actually trading off the vaccine for other interventions,” O’Brien said.
The RTS,S vaccine is administered to children in four doses — which is in itself a challenge because this is not the norm for childhood immunizations, said Andrew Jones, principal adviser at UNICEF Supply Division’s Vaccine Centre.
But in the pilot data, there was still high impact reported in instances where there was “relatively modest fourth dose coverage,” O’Brien said. Because of this, moving forward, if the data guides them in that direction, WHO may modify the recommendation around the need for this fourth dose.
And the supplies of the two vaccines are sufficient. After the first RTS,S vaccine was approved in 2021 — there were concerns about whether there would be adequate supply for large-scale rollouts. But with the approval of the second vaccine, the supply has broadened, “which means we won't have this constraint we were worried about,” Jones said.
GSK is the manufacturer of the RTS,S vaccine and Serum Institute of India is manufacturing the R21 vaccine.
GSK is in the process of a technology transfer of the know-how on manufacturing this vaccine to India-based Bharat Biotech. The Serum Institute of India is also working on agreements with local manufacturers in Nigeria and Ghana to produce the R21 vaccine, Jones said.
“The agreements, as far as I know, are confidential,” he said.
And beyond supplies reaching countries, national governments are working through the logistics of launching their rollouts. Preparing communities to accept the vaccination campaigns is a key component of that.
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“Most vaccines come with a lot of conspiracies, with a lot of rumors and myths, and understanding those dynamics within communities will help in the acceptance of these vaccines,” said Mbianke Livancliff, senior immunization officer at Value Health Africa, a nongovernmental organization working in Cameroon and other Africa nations.
They’ve been laying the ground with communities in Cameroon by telling them about the importance of the vaccine and explaining the rigorous processes undertaken to ensure their safety.