In 2019, there were estimated 229 million cases of malaria worldwide while malaria deaths stood at 409,000. Children accounted for 67 per cent (274,000) of all malaria deaths worldwide. Both current and previous deaths have been a source of concern to the world community, especially how to curb the preventable mortality. Experts say wide use of new malaria vaccine, the RTS,S could turn the tide in Africa, writes APPOLONIA ADEYEMI
The death of two Nigerians, Adanma Jimoh and Elo Ogboru, in their 30’s from malaria is a reminder that the disease has continued to cut the lives of people in their prime despite the general notion that it’s a common ailment Nigerians can manage and treat conveniently. Adanma Jimoh (34) died at the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, in October 2020, of malaria.
She had lived with the fever for over six weeks, but chose to do home treatment. With her condition going from bad to worse, it got to the stage that she could no longer walk or speak and was eventually rushed, under emergency to LUTH. Sadly, four days after the hospital admission, she died.
The diagnosis was severe and complicated malaria. Also, Elo Ogboru (38) died on February 9 at the Matogun area of Ogun State. Days before she died in a private hospital at Matogun in Ifo Local Government Area, Elo, who had been very ill, initially presented with fever, headache, shrills and body aches.
The patient, who did not bother going for a diagnostic test, assumed the symptoms were those of malaria, did home treatment, procured Fansidar tablets from over-thecounter in a patent medicine store in her neighbourhood and administered them on herself.
After eight weeks of self-medication, her condition became severe. Her siblings, who came visiting when they did not hear from her for days, met her on bed, incapacitated: she was vomiting and appeared very lean and unhealthy. She was consequently taken to a private hospital where the diagnostic test showed she had severe malaria. The doctors battled to bring her to a stable condition and four days after, Elo was discharged and taken home.
Her elder brother, Kenule Ogbo-ru, told the New Telegraph that Elo was not feeling well even after being discharged from the facility. She, however suffered a relapse and was promptly taken back to the hospital, but was pronounced dead two hours afterwards.
The doctor, who was sad about the development, kept telling Elo’s siblings: “The malaria attack she suffered as observed under lab examination was very high. The malaria was high; it has already done irreparable damage to Elo’s health before medical intervention reached her.”
Elo’s death elicited shocking reactions from her friends and neighbours. Some of them even doubted that malaria was the cause of her sudden death. This has always been the reaction anytime news filtered in that a particular death is attributed to malaria. Sceptics often do not believe that malaria, a very common ailment in Nigeria, can result in death. However, the reality is that malaria is a killer disease, affirmed Dr. Nnenna Ogbulafor, Head, Case Management at the National Malaria Elimination Programme (NMEP), Federal Ministry of Health (FMoH).
Sadly, young Nigerians are not the only victims that malaria kills. Available data shows that children under five years are the worst hit when it comes to both malaria incidence and deaths. Children most at risk of malaria According to the 2018 Demographic Health Survey (NDHS), in Nigeria, 23 per cent of children aged six to 59 months tested positive for malaria by microscopy. However, malaria prevalence in the general population declined from 42 per cent in 2010 to 27 per cent in 2015 and now to the current level of 23 per cent in 2018. Despite that, more than 60 per cent of malaria occurs in children, particularly under five who with pregnant women are most at risk for malaria. Ogbulafor said: “That is why most of the interventions are hanging around children under five and pregnant women because these are the vulnerable age groups for malaria.”
According to Ogbulafor, the effect of malaria is worse in children. Explaining the huge impact of the disease on kids, she said, “the plasmodium parasite causing malaria attacks the red blood cell. Subsequently, when an infected child comes down with uncomplicated malaria, if that child is not properly attended, this parasite will continue to multiply in the blood, in the system and in the body.
“If you don’t intervene with appropriate medicine to treat that child, the parasite will continue to destroy the red blood cell, leading to anaemia, meaning lack of adequate blood.” According to her, when that happens, the whole lot of organs is affected: the heart, kidney, the brain and consequently, that child comes down with severe malaria. She added: “At this stage, severe malaria is the malaria with complications; the heart can now be affected and the kidney can fail as well because blood in the body is inadequate. Also, the brain being affected can make the affected child go into a coma and that is why we sometimes see such children convulsing.”
At this point the malaria becomes a life-threatening condition and there will be a lot of battle to save that child, added Ogbulafor. It is against this background that the World Health Organisation (WHO) is adopting innovative tools, medications from research and development to tackle malaria not only in malaria endemic regions but at the global level. To this end, the UN agencies have fixed the target date of 2030 to eliminate malaria worldwide.
Not surprisingly then,the world body recently introduced the malaria vaccine with a view to intervene and curb unnecessary deaths in children in malaria endemic countries and other parts of the world where malaria burden has persisted. According to the WHO, in 2019, there were an estimated 229 million cases of malaria worldwide while the estimated number of malaria deaths stood at 409,000 in the same year. In 2019, children accounted for 67 per cent (274,000) of all malaria deaths worldwide. On its part, the WHO African Region carries a disproportionately high share of the global malaria burden.
In 2019, the region was home to 94 per cent of malaria cases and deaths. According to the WHO, new and complementary tools are needed to further drive down malaria cases and deaths, with a view to ultimately achieving the vision of a world free of malaria. Today, a first-generation vaccine known as RTS,S/ AS01 (RTS,S) which has the potential to strengthen efforts to control malaria in Africa and save tens of thousands of young lives, has been introduced; currently it is at a pilot trial stage in three African countries: Ghana, Kenya and Malawi .
The RTS,S vaccine is the first and, to date, the only vaccine to show partial protection against malaria in young children. It acts against Plasmodium falciparum, the most deadly malaria parasite globally and the most prevalent in Africa.
Rigorous clinical testing in seven African countries has shown its potential to boost malaria prevention and save lives. Among children who received four doses in large-scale clinical trials, the vaccine prevented four in 10 cases of malaria over a four-year period and three in 10 cases of life-threatening severe malaria.
In view of its public health potential, WHO’s top advisory committees for malaria and immunisation have jointly called for phased introduction of the vaccine in several settings in sub-Saharan Africa. The vaccine will be used as a complementary malaria control tool, added to the core package of WHO-recommended measures for malaria prevention.
In large-scale clinical testing involving thousands of African children, the vaccine was generally well tolerated, with adverse reactions similar to those of other childhood vaccines. In 2015, the European Medicines Agency – a stringent regulatory authority – issued a positive scientific opinion of RTS,S, indicating that the benefits of the vaccine in preventing malaria outweigh potential risks. Similarly, the national regulatory authorities in the three pilot countries have since reviewed and authorised the RTS,S vaccine for use in phased introductions in their countries.
RTS,S was developed over a 30- year period by GSK, including through a collaboration, begun in 2001, with PATH’s Malaria Vaccine Initiative (MVI) and a network of African research centres. A five-year Phase 3 efficacy and safety trial was conducted between 2009 and 2014 through a partnership that involved GSK, MVI and research centres at 11 sites in seven African countries.
Malaria vaccine implementation programme
This pilot implementation programme is a country-led, WHO-coordinated initiative. It is a collaborative effort with Ministries of Health in Ghana, Kenya, and Malawi and a range of in-country and international partners, including PATH, a non-profit organisation, and GSK, the vaccine manufacturer. Commenting on the vaccine trials, Ogbulafor said the world community is awaiting the outcome of the vaccine pilot so that all other countries where malaria is endemic can deploy the medication based on lessons learnt.
Experts say the rapid uptake of the malaria vaccine has the potential to save thousands of lives that may have died from the disease. Therefore, delivering the vaccine will contribute to maximise the benefits of other malaria interventions, considering that the vaccine is not a stand-alone tool, but being used alongside other malaria interventions, said Dr. Mary Hamel, the Lead for Malaria Vaccine Implementation Programme at the WHO and Mr. John Bawa, who is Africa Lead, Vaccine Implementation at PATH.
The duo made their views known during a recent virtual media briefing on Malaria and COVID-19. To date, more than 350,000 children have received the RTS,S vaccine across Ghana, Kenya and Malawi. According to Hamel, administering the malaria vaccines on citizens will be in addition to using malaria interventions including insecticide treated nets, which is another important malaria control intervention now used by 50 per cent of people at risk of malaria. She said: “This vaccine is delivered through this robust malaria intervention programme that is already available and functioning.
“Just a year after the vaccine was introduced, 70 per cent to 80 per cent of children in the countries where the vaccine was trialled have been administered with this vaccine and this is remarkable.” Speaking in a similar vein, Bawa said if this malaria vaccine is used widely, it has the potential to save tens of thousands of young lives in Africa.
In addition, he said the vaccine will drive down malaria as a disease cutting measure. According to Bawa, the progress from malaria fight has stalled because all these other measures seem to have been stagnant in terms of their impact.
“Therefore, there is a need to add an additional measure in order to accelerate the rate at which we want to end malaria from the south of Sahara.” He described the vaccine as the most promising tool that can be included in the resource in order to be able to manage malaria. Also, he noted that vaccines are one of the most powerful tools to achieve health goal in order to reach the most vulnerable children.
“This is especially important during the COVID-19 pandemic to reduce cases of malaria so as to leave health facilities for cases of severe illnesses when hospitals were under strain because of the coronavirus pandemic. Speaking on other factors that can help to cut malaria incidence and deaths, Ogbulafor urged the three tiers of government to put more resources on the table.
She added: “For now, malaria is majorly donor-driven; government needs to do more by putting more money on the table.” “For officials, it is important that we continue to use the money right and implement more impactful, efficient interventions including using the chemoprevention, the use of ITPT, the intermittent preventive treatment for pregnant women, insecticide treated mosquito nets for children under five and across board because everybody is prone to malaria.” Ogbulafor urged health workers to adhere to malaria treatment guidelines which are to diagnose first because one of the manifestations of malaria is fever and a whole lot of other infections manifest in fever.
she said: “If you don’t diagnose to be sure that it is malaria, you may just be treating that infection when it is not malaria; that is when people complain that the drugs are not working. “For instance, when you use Flagyl tablets to treat malaria, it will not be effective. Hence it is important that we do the diagnosis. It is also important that the care workers delivering services do the right things considering that prompt and early treatments are key. “If you are not treated on time, the disease moves to the next phase which is severe malaria and most that are affected with severe malaria don’t survive.
“At the individual level, it’s important for the media to harp on the need for prevention, using chemoprevention therapy and the ITPT on pregnant women three months after conception, until delivery. It is also important for them to use everything to complement, such as the use of bed nets to ensure that everybody sleeps under nets.
“Besides, when you suspect that you have fever, go to the appropriate health facility and then the health facility should first diagnose that it is malaria. Thereafter, start the right treatment with the appropriate drug, which is artemisinin combination therapy (ACT) early to avoid the ailment from moving to the next phase of severe malaria.”