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Malaria vaccine: We mustn’t abandon other tools for reducing malaria –Medical experts

‘WHO recommendation justifies our relentless campaign for malaria vaccine’

The sub-Saharan Africa is said to be home to more than 90 per cent of malaria deaths worldwide, with many areas of moderate to high transmission. This may be why the WHO recommended widespread immunisation of children across sub-Saharan Africa and elsewhere with the world’s first vaccine against malaria, excites many. Isioma Madike, in this report, captures the reactions of medical experts of this novel vaccination aimed at putting a stop to this killer illness

The first vaccine for malaria, the mosquito-borne disease, marks a turning point in a battle against the parasite that causes malaria. It is hoped that when proper vaccination starts, it will put a stop to the nightmare the deadly ailment, which kills over 400,000 people each year, according to the World Health Organisation (WHO), has taken humanity through.

It is set, the world health body further said, to be deployed more widely after more than three decades of work and about $1 billion in investment. The vaccine was developed by GlaxoSmithKline Plc. and its partners before winning a recommendation from the WHO for use, especially in children in sub-Saharan Africa, and other regions with moderate to high transmission. Since this cheering news, medical experts, particularly those in public health, have been reacting.

A Public Health expert, Prof. Bayo Onajole, while applauding the innovation, said that the vaccine for malaria has been in preparation for over 30 years. He also pointed out that malaria has been a major sickness that causes death, especially in the tropical region of which Nigeria belongs to. According to him, a malaria vaccine that is effective will be saving so much for the country.

He said: “We will be saving the cost of sickness, death, and absenteeism. Malaria, we should also know, affects mostly under-5 children and pregnant women. We have a lot of pregnant women, who have died, even their inborn babies also as a result of malaria. So, I believe that if we can lay our hands on preventive measures like the vaccine, it will go a long way in helping our wellbeing.

“But, with the vaccine, we should still ensure that we continue with the other control measures in order to effectively put malaria in check. Such measures include keeping our environments neat because it’s not only malaria that is got from dirty environments.

So, if we can keep our environment neat, it will affect us positively. “Also, the use of insecticides should not be jettisoned; this is because the mosquito, which acts as the vector for malaria, can also cause other diseases like Yellow Fever.

By adhering to all these preventive measures, we will succeed in preventing other diseases, the reason we must not discard those environmental measures is because we are now looking up to the malaria vaccine.” Another Public Health physician, Dr. Doyin Odubanjo, also said that the vaccines means there is now available another tool for combating malaria, especially in children. The vaccine, Odubanjo said, is effective enough in reducing the cases of severe malaria even though it is not generally highly effective, and its effect wanes quickly also.

He said: “This means that we must not abandon the other tools for reducing malaria such as insecticide-treated nets, clean effective drainages and environment, and general development. Health officials in each country have to determine the cost effectiveness of introducing the vaccines in their respective individual countries.

It’s only after this they can begin to examine further issues around introduction, such as when to give the children.” Maduike Ezeibe, a Professor of Veterinary Medicine and Clinical Virology at the Michael Okpara University of Agriculture, Umuahia, Abia State, however, is of the belief that a vaccine for malaria, like many rightly observed, is long overdue. According to him, from the beginning people in sub-Saharan Africa have been more tolerant to malaria, showing that exposure to the antigen leads to immunity unlike COVID-19, which has been reported to reoccur in recovered people in such a short time.

As for people’s skepticism, the professor said, effort to force people to accept any vaccine or treatment will never work. People, he added, will watch how the vaccine works and start accepting it as they see its efficacy. “However, it will just be an additional measure to existing measures because the causative agent of malaria, plasmodium, has many hosts (animals). So, it is easier to think of eradicating or controlling the vector (mosquito) than the disease-agent.

To eradicate any disease- agent or even effectively control it, its method of spread, its hosts range, how long immunity from exposure to it lasts and age limit to disease it causes must be properly (not hurriedly) studied. Malaria has no age limit.

“Its agent has many hosts (animals) but from herd immunity that exists in Africans, its immunity lasts reasonably long enough and it cannot be transmitted if the vector is cut off. So, vaccines can be used as additional help to individuals, who choose to be vaccinated. It may not be a significant help to any population. Science should not be by sentiment of who you are or where you come from.

Every claim should be backed by scientific reasons,” Ezeibe said. A Family Physician and Primary Care Paediatrician, Dr. Rotimi Adesanya, also noted that the innovative vaccine is very effective in protecting malaria in children, and as a result children, he said, will be the target. Adesanya is, however, suggesting that it will be added to the other vaccines given to children during their visit for other vaccinations. Nigerians, he said, should know that the vaccine is safe, it will be free, and it will not lead to death and will not cause infertility. Once they are reassured about all this, the doctor said, the citizens will have no reason not to cooperate by accepting it.

Adesanya said: “We have to start aggressive health education, make the vaccine mandatory for primary school pupils for enrollment in schools. Vaccination exercise should also be made house to house like the statewide polio exercise. But, chances of early roll out in Nigeria include strong political will, advocacy, seeking for help from donor agencies and adequate budgetary provision for it in 2022. “The vaccine however, cannot replace all other non-pharmacological measures. We still need to cut grasses, get rid of stagnant water, do aerial spraying of insecticides and use insecticide treatment nets.

The funding is possibly no problem; we have donor agencies like GAVI, Global funds, IFC, Bill and Melinda gates, and so on, who are funding vaccines all over the world. Presently they are funding over 10 childhood vaccinations in the country. “Adding malaria to it will not be a problem. I will advise we start with under- 5 children, sickle cell patients, and pregnant women, who are at high risk. We may not be able to fund the whole population as it stands now.”

The Prince Ned Nwoko Malaria Eradication Project also hailed the approval by WHO for wide-use of the malaria vaccine in countries and the endorsement of the Foundation to coordinate the national response to implement the jab in Nigeria. WHO recommendation, he said, justifies the Foundation’s relentless campaign for malaria vaccine. Recall that the Foundation, a non-governmental organisation, through its Malaria Eradication Project, had sought and received approval from the Federal Ministry of Health to support and coordinate a national response toward malaria control and elimination through strategic partnerships to promote and implement the malaria vaccine in Nigeria.

The Foundation, according to reports, believes that as a country with the highest malaria burden globally, a strong local response is urgently required to achieve targets set in the National Malaria Strategic Plan (NMSP, 2021-2025). Chairman and founder of the Foundation, Prince Ned Nwoko, had earlier said a technology-driven solution for effective malaria control and elimination through the use of vaccines, in addition to existing interventions, is critical to attaining set targets for Nigeria in the light of the high malaria mortality and morbidity burden.

The statement had added: “The Prince Ned Nwoko Malaria Eradication Project invites the public and private sector partners to come on board, as efforts are currently on to establish a strong multi-sector partnership to drive this great process that also requires the optimal use of existing interventions, in addition to the vaccines to deploy a comprehensive package for effective malaria control to elimination.” Just recently, the Foundation collaborated with the WHO to co-host a virtual sideline event tagged Global Action for a Malaria Free Africa (GAMFA) during this year’s United Nations General Assembly in New York.

The aim was to discuss the critical need of accelerating not just the control and elimination but eradication of malaria in Nigeria and Africa. Prince Nwoko had been engaging the UN and the WHO together with other stakeholders in his relentless campaign to push the anti-malaria programme in Africa above the threshold of control and palliatives to total eradication through a multi-faceted approach. He had observed that vaccines were invented against COVID-19 even at a stage when the true causative factors of the pandemic were still a mystery.

He had also reasoned that malaria disease, which has mosquitoes clearly identified as its cause, ought to present lesser challenges with regard to vaccine research. In spite of all these, some researchers, according to reports, fear that the excitement over the vaccine will overshadow existing malaria control measures that are already often underfunded, including Nwoko insecticide programmes and functional health systems. “I respect the researchers involved with this massive effort, but the reality is that so much money has been poured into this vaccine, even when the results from studies are disappointing,” said Badara Cisse, a malaria researcher at the Institute for Health Research, Epidemiological Surveillance and Training in Dakar, as quoted in one report.

“I don’t think a 30% effective vaccine would be acceptable for Americans,” Cisse added. Some other experts have said that malaria elimination requires a combination of complementary innovative tools and approaches tailored to local contexts to avoid a one-size fits all approach.

But, Matshidiso Moeti, WHO regional director for Africa was quoted in a statement as saying that the recent recommendation, offers a glimmer of hope for the African continent, which shoulders the heaviest burden of the disease. “We expect many more African children to be protected from malaria and grow into healthy adults,” countered Gavi, the Vaccine Alliance, GSK and Med- Access. “There was a financing agreement in August to ensure continued production of the vaccine, the first to prove safe and effective in a large, late-stage trial.” Gavi said at the time that its board would decide after the WHO decision whether to finance a new malaria vaccination programme for countries in sub-Saharan Africa. A study of 6,000 children, published in August, found that the combination of antimalarial drugs and vaccination lowered hospitalisations and deaths from the disease by about 70 per cent after three years. Early development of the shot is said to have begun around 1984. Malaria, reports say, has been a tricky target for vaccine makers, but researchers are believed to be making progress. A shot said to have been developed for the disease at the University of Oxford earlier this year became the first to meet a WHO goal of more than 75 per cent efficacy in a mid-stage study. BioNTech SE, meanwhile, according to reports, is however seeking to follow its successful COVID-19 vaccine with one to prevent malaria. Malaria, according to WHO, preys heavily on vulnerable, marginalised populations, including children under-5, pregnant women, indigenous people, refugees, and displaced individuals. Despite considerable progress with greater use of insecticide-treated bed nets, indoor residual spraying, and the adoption of highly effective treatments, malaria remains a primary killer of children in sub-Saharan Africa. While malaria deaths are said to have been cut in half since 2000, the recent recommendation—based on the advice of WHO’s global advisory bodies for immunisation and malaria—comes at a time when progress against malaria is said to have stalled or reversed in some areas. Malaria continues to be both a cause and effect of poverty and inequality. WHO and partners have called for new tools, including malaria vaccines, to help get malaria control efforts back on track, improve child health, and save lives. Layering the malaria vaccine with other highly effective prevention tools, such as mosquito nets, indoor residual spraying, and wider community case management can increase equity in access to malaria prevention and help reach those that are being left behind. But, Nigerians, it appears are no longer using the long- lasting insecticidal nets freely distributed by government and non-governmental agencies to combat the scourge of malaria, said to be the most prevalent disease in the country. In poor neighbourhoods, it is common for families to continue to use conventional insecticide nets without proper re-treatment; this, according to experts, reduces their effectiveness considerably. One of the reasons though is that the chemicals for re-treatment are not readily available and have a cost that families cannot always afford. This, however, may be the reason the government has continued to stress the importance of Long Lasting Insecticide Net (LLIN), particularly those living in mosquito-prone localities. But investigations have shown that many residents of poor neighbourhoods have dumped the nets freely distributed to them via primary health centres to combat the scourge of malaria. This recent attitude follows allegations of severe adverse reactions, body itching and rashes, which people claimed to have experienced shortly after sleeping under the net. However, the long-lasting insecticide nets, according to medical experts, have proved more efficient than the conventional Insecticide Treated Nets (ITNs) because they do not need re-treatment and have a life span of three to five years. According to a recent World Bank Malaria Control Booster Project report, one out of every three children under five years old dies of malaria in developing countries of which Nigeria is one of them. Another of its reports was also quoted as saying that one out of every three children under-5 years old dies of malaria in developing countries of which Nigeria is one of them. Nigeria is also said to have the highest number of malaria cases in the world, contributing about 23 per cent to the global malaria burden, according to available statistics. In view of the high prevalence, the Federal Government has consistently advocated the use of long-lasting insecticidal nets as the most effective way to combat the scourge. The states also keyed into this programme. For instance, well over a million insecticides treated nets had been distributed in Lagos State since 2000 to mothers of children under the age of five years. This is usually done either during integrated programmes with immunisation campaigns or during stand-alone campaigns in many, if not all, of the local government areas of the state. Insecticide treated nets are low cost and are said to be a highly effective way of reducing the incidence of malaria in people who sleep under them. This, according to medical experts, has been conclusively shown in a series of trials to substantially reduce child mortality in malaria-endemic areas. By preventing malaria, treated nets reduce the need for treatment and the pressure on health services, which is particularly important in view of the increase in drug resistant falciparum malaria parasites. This realisation has made the promotion of treated nets the core of malaria eradication programme through free distribution in addition to other methods recommended by the WHO. The other methods include IRS, Intermittent Preventive Treatment (ITP) for pregnant women, and Rapid Diagnostic Test (Ruts) kits. The Federal Government was said to be working towards ensuring the use of 63 million treated nets by at least 32 million households in the 36 states and the Federal Capital Territory before 2020. It was expected to reach 80 per cent of pregnant women and children below five years in the country. Unfortunately, this massive distribution, which was supposed to be the largest in history in any known part of the world, failed due mainly to insincerity on the part of the government, according to those who should know. Malaria is an infectious disease caused by the parasite genus plasmodium. The four identified species of this parasite causing human malaria are plasmodium falciparum, plasmodium vivax, plasmodium ovale, and plasmodium malariae. In Nigeria, 98 per cent of all cases of malaria are due to plasmodium falciparum. This is the species that is responsible for the severe form of the disease that leads to death. It is transmitted from bites of an infected female anopheles mosquitoes to man. This makes the disease highly endemic in the country. It poses, according to the authorities, a major challenge to the country as it impedes human development. It is said to be both a cause and consequence of underdevelopment and remains one of the leading causes of morbidity and mortality in Nigeria. It is also said to be responsible for 29 per cent of childhood death, 25 per cent of infant mortality and 11 per cent of maternal mortality. The most vulnerable groups are under-fives, pregnant women, visitors from non-endemic areas, those with sickle cell anaemia, and HIV/ AIDS patients. However, a study published in the records of African Medicine by Dr. Best Ordinioha of the Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, was quite revealing. It stated that the use of the treated mosquito nets is often jettisoned in periods of low mosquito activity and high night time temperature by Nigerians. According to the study, all the 170 respondents in a semi-urban community in Rivers State had treated nets but only 71.8 per cent had hung the nets as at the time of the survey; 83.6 per cent hung the nets over a bed, while 10.7 per cent used the nets as window curtains. Of the 102 treated nets that were properly deployed, only 27.5 per cent were occupied the night before the survey, by an average of 2.5 persons, mainly under-5 children. “Proper health education is required to encourage the consistent use of the nets, even on hot nights, with low mosquito activity,” the author said.

 

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