Leisha Goel is a staff writer for Brief Policy Perspectives and a first-year MPP student.

After more than 130 years since the malaria-causing parasites were named by the scientific community, the first vaccine shown to prevent the disease has been approved by the World Health Organization. Hailed as a breakthrough in vaccine development and public health, the RTS,S malaria vaccine, also known by its brand name Mosquirix, has been decades in the making. Which leads to the question – what’s next? 

Malaria: The World’s Oldest Pandemic

Each year malaria kills over half a million people, with approximately 95% of those deaths occurring in Africa. Of those victims, approximately 260,000 of them are under the age of 5. The latest world malaria report published by the WHO found that while their worst-case predictions – a doubling of the number of malaria deaths – did not come to fruition,  “moderate disruptions to malaria services led to a marked increase in cases and deaths in 2020 over the previous year.” In 2020, there were an estimated 241 million malaria cases worldwide with 627,000 fatalities reported. In comparison to 2019, the report states that there were 14 million more cases and 69,000 more deaths. Approximately two-thirds of these additional deaths (47,000) were reported as being linked to disruptions in malaria prevention outreach, diagnosis, and treatment during the COVID-19 pandemic.

While the worst projection of malaria cases and fatalities in 2020 was avoided, the report shows that there were more cases and deaths than there were a decade ago, with Africa enduring the greatest toll. Despite the urgent need for scientific advancement in the prevention of malaria, the world’s oldest pandemic, progress on fighting malaria has stalled due to the continued prioritization of the COVID-19 pandemic. 

Mosquirix: The First Vaccine of its Kind

Unlike COVID-19, malaria is not a virus but a parasitic disease, making it much more difficult to understand than viruses or bacteria. In fact, the new RTS,S malaria vaccine is not just the first vaccine ever approved to fight malaria; ​​it is the first vaccine developed for any parasitic disease.

The RTS,S vaccine has been in development since 1987, with more than $750 million spent on research, development, and testing. Funded largely by the Bill and Melinda Gates Foundation and the London-based pharmaceutical company GlaxoSmithKline (GSK), the vaccine has already undergone clinical trials and a WHO-recommend pilot study in Kenya, Ghana, and Malawi. 

During the duration of the pilot study, 2.3 million vaccine doses were distributed through pilot programs with funding given in part by Gavi, the Vaccine Alliance, a Swiss-based health partnership. The reports from the clinical trials and pilot programs found that the hospitalizations from severe malaria decreased by about 30% with the vaccine. While these modest results caused some skepticism about the vaccine, the decrease in severe malaria is considered to be a major win, as severe malaria accounts for up to half of malaria-attributed deaths. 

It is because of malaria’s prominence in Sub-Saharan Africa that the WHO gave its seal of approval for the vaccine to be distributed despite its moderate efficacy; the rationale being that vaccine distribution would help mitigate hospitalization rates for malaria as one step towards decreasing annual malaria deaths. And even when malaria is not fatal, the repeated diagnosis of malaria, which frequently occurs in Sub-Saharan Africa, can permanently alter the body’s immune system, leaving malaria-infected individuals vulnerable to other illnesses and diseases.

The WHO has recommended that children living in regions with moderate to high levels of malaria transmission should receive four doses of Mosquirix. The four doses are administered in three doses given between the ages of 5 and 17 months and the fourth given about 18 months later. Additionally, recent research suggests that countries might achieve even greater drops in hospitalizations and deaths through tailored rollouts of the vaccine to coincide with malaria’s annual peak season by administering the vaccine in conjunction with seasonal malaria chemoprevention, a treatment in which healthy children take a monthly dose of antimalarial drugs to help prevent the disease.

What Now?

Now that a vaccine has been approved by the WHO, Sub-Saharan African countries are now facing a new obstacle: stocking and distributing the vaccine. In addition to deciding how to deploy the vaccine, countries must determine how many doses their population needs, how much it will cost to purchase, and distribution logistics.

Approximately 100 million doses of Mosquirix will be needed annually to vaccinate all children in high-risk countries worldwide. As of now, GSK has pledged to make 15 million doses available annually at just above the cost of production. In addition, Gavi has announced its decision to commit $155.7 million to finance malaria vaccine introduction, procurement, and delivery for Gavi-eligible countries in Sub-Saharan Africa over the next three years. At a potential cost of about $5 per dose, researchers suggest the vaccine rollout, including its distribution, would cost around $325 million each year across just ten Sub-Saharan African countries with high malaria incidence rates. 

Some researchers fear that countries may be too hasty in investing in the vaccine without any plan to roll out the vaccine. Part of their rationale stems from the current lack of funding for existing malaria control measures, such as insecticide programs and functional health systems, despite their effectiveness. Another concern is that the same streams of misinformation that have hindered the distribution of the COVID-19 vaccine may also impede the distribution of Mosquirix. However, health officials in Sub-Saharan Africa are right now more concerned with the issue of funding than any existing or future problems with distribution and anti-vaccine sentiment. 

For centuries, malaria has caused immense suffering worldwide, and the introduction of Mosquirix offers a new weapon to fight against malaria – particularly for the continent shouldering the heaviest burden of the disease. The progress in the fight against malaria has stalled for the past 5 or so years, but the WHO’s approval of a malaria vaccine, even if only moderately effective, has inspired researchers and advocates to re-prioritize on building upon the more than 30 years of malaria research to help eradicate malaria. With the first malaria vaccine and a reinvigorated sense of purpose, we may be closer than ever to ending history’s oldest and deadliest pandemic.