Is the first malaria vaccine worth the cost?

In October 2021, the World Health Organization recommended the expanded use of the first malaria vaccine — RTS,S or Mosquirix — among children living in regions with moderate to high malaria transmission. The vaccine, which is still in the pilot phase in Ghana, Kenya, and Malawi, will soon be rolled out nationally. 

John Tanko Bawa, the vaccine implementation team lead for Africa at PATH-Centre for Vaccine Innovation and Access, said the vaccine is a significant step forward for malaria control, child survival, and health equity. He said the immunization substantially reduces malaria illness and death and could save the lives of an additional 40,000 to 80,000 African children each year. In 2020, one African died from malaria every minute.

“New tools, such as this vaccine are needed to help fight this disease that has been around for millennia. This new tool, the malaria vaccine, is needed now more than ever,” Tanko Bawa said.

Following the landmark WHO recommendation, Tanko Bawa said the expansion of malaria vaccination in the pilot countries — Ghana, Kenya, and Malawi — is set to take place.

“Preparations are underway for the first step, which is to vaccinate children in pilot areas that have not yet received the vaccine, beginning this year. Next steps will include applying for support from Gavi, the Vaccine Alliance, for broader subnational use of the vaccine in areas of greatest need," he said.

Tanko Bawa said that the U.S.-based Open Philanthropy has provided a grant of $5 million to PATH, which will support the expansion of the vaccine in the pilot areas in Kenya, Ghana, and Malawi through the end of 2023, using vaccine doses donated by the manufacturer GSK. The grant will also allow PATH and WHO to continue providing technical support to the three countries.

But some experts have questioned the wisdom of rolling out the vaccine due to its relatively high rollout costs and low levels of efficacy at 30%. Citing the shot’s low efficacy, short-term immunity, high price, and limited supply, the Bill & Melinda Gates Foundation — financiers of vaccine development — decided that it would not directly support the vaccine rollout.

Kate Davidson, media relations officer-global communications at the Gates Foundation, told Devex that the foundation concluded that its direct investments could have a greater impact “by supporting the delivery of existing tools and research and development for potentially transformative tools like second-generation vaccines, monoclonal antibodies, and attractive targeted sugar baits.”

Davidson said while there is no single, silver-bullet tool to end malaria, countries need access to a mix of effective tools to drive down cases and ultimately eradicate the disease.

"While efficacy of RTS,S is low, RTS,S gives national malaria control programs another option to consider in their mix of interventions informed by local disease context," she wrote in an email.

Scientists identified the logistics needed, funding, administration of the four-dose vaccine, and follow-up as potential barriers to nationwide implementation in Ghana.

Ghanashyam Sethy, a health specialist at UNICEF Malawi, said that while the vaccine is “expensive and logistically challenging to deliver” — to facilitate implementing countries’ and donors’ budget planning, a price of €9.30 (almost $10) per dose will be maintained as a ceiling price during the period of the current supply agreement — 2023 to 2025.

But at the recommended four-dose schedule, the total cost of the vaccine —  €37.20 per individual — “will present some challenges for many countries” and will “be the most expensive vaccine in the Gavi portfolio requiring co-financing," he said.

But other studies found that the vaccine is cost-effective if you consider the change in health outcomes and deaths averted.

Boston Zimba, malaria vaccine implementation program technical officer at WHO Malawi, said that data from the pilot program indicates that more than two-thirds of children in the three pilot countries — who were not sleeping under a bed net — benefited from the RTS,S vaccine.

"The malaria vaccine is implemented as a routine vaccination exercise where parents are supposed to bring their children to a designated health facility hence the issue of logistical challenges to deliver does not arise,” he said. “From the pilot phase we have observed high acceptance of the vaccine with a 92% turn out and we hope this will be the case with the other phases."

Adamson Muula, professor and head of community and environmental health at Kamuzu University of Health Sciences, added that preventing one death among 200 vaccinated children is worth the cost.

"Any single life that is saved is worth the money that is invested, the RTS,S is a start among the malaria vaccines that have ever been developed. With the experience from the RTS,S, new other more efficacious vaccines are likely to be developed," Muula said.

Update, Dec. 9, 2022: This article has been updated to clarify that the Bill & Melinda Gates Foundation decided that it would not directly support the RTS,S vaccine rollout.