Uganda takes the lead on malaria vaccines

Contrary to a Reuters report that Uganda has approved the latest malaria vaccine, top local experts say they’ve been in touch with their Ugandan counterparts to discover this was not so.

“The Ghanian malaria chief is in the US right now and told me she woke up to twenty missed calls today, (Friday, 14th June), wanting to know what was going on! The WHO hasn’t even approved it. The reality is Ghana is in discussions with the Oxford University vaccine researchers about approving an in-country trial, and they’re exploring the potential for a manufacturing plant to be built and housed there,” said one long-standing malaria NGO chief who declined to be identified.

The vaccine which has shown a 77% efficacy in children, has been in development for over five years, is not a health priority in South Africa – the ongoing Phase Three Oxford trial results are pending, and a data quality check still must be made. That’s according to Prof Karen Barnes, Co-chairperson of SA’s Malaria Elimination Committee, who adds that there’s major scientific and political local support for scaling up the SA manufacturing capacity for all vaccines during the current global Covid pandemic lull.

“With the backing of GAVI (the Global Vaccine Alliance), we want to ensure that all the scaling up for Covid doesn’t peter out and that the manufacturing capacity can be used for other diseases. The intention is to maintain an elevated level of production to enable a global, (but particularly African), impact, with or without Covid,” she added.

There are two vaccine facilities in South Africa, the Gqeberha (Port Elizabeth) ‘fill and finish” factory and the Biovac plant in Cape Town, the former tooling up to State-of-the-Art vaccine production, using global technology transfer.

SA malaria control – a success story

In South Africa, the malaria threat has been hugely mitigated, deaths dropping from 331 in 2017 to 28 in 2020, to less than half that currently – via mobile test and treat units patrolling the country’s borders, and vector control in the endemic areas of northern KwaZulu Natal, Limpopo and Mpumalanga.

The experts say that even without the vaccine, SA has enough tools to get to zero local (non-imported) transmission within five years, the now-extended government target. Should a vaccine be approved by the WHO and SA’s Health Products Regulatory Authority, it could be added to the armament.

Barnes said data emerging from the WHO summit for malaria-eliminating countries held in Cape Town this January showed that KwaZulu Natal was leading the way in achieving “sub national certification of malaria elimination.”

“Nationally we have about five million people living in malaria-endemic areas, but the risk is extremely low. Our work in KZN will pave the way for the other two provinces,” she says.

The Mitigating Antimalarial Resistance Consortium in Southern and East Africa, on which the UCT-based Barnes serves, recently received 4,2 million Euros from the European Union research and innovation program for spending over four years. Gains achieved in reducing the burden of malaria are threatened by malaria parasites becoming resistant to the main group of drugs used to treat the disease (Artemisinins).

Vax resistance a real threat

The potential impact of widespread Artemisinin combination resistance in Africa has been estimated at 16 million more malaria cases and nearly 80 000 additional malaria resistant deaths annually. Protecting the efficacy of current first line malaria treatments is thus a top public health priority. The consortium will provide technical support to 18 countries of Southern and East Africa, the areas historically first affected by drug resistance.

The Oxford malaria vaccine’s remarkable efficacy is being put down to it having leveraged off the successful Novavax COVID-19 vaccine technology. An estimated two-thirds of malaria deaths are among children under the age of five, most of them in Africa.

Africa is the world’s hardest-hit continent. The previous four-dose malaria vaccine candidate reached 50% efficacy over a two-year administration period, creating major adherence problems and consumer resistance.

In Mozambique, 9,3 million people contracted malaria in 2020 versus just 8 000 annually in South Africa, (2020 NICD figures).

According to the WHO, the disease kills a child every two minutes globally.

The disease has severe secondary effects, including stunting and slowing or severely impairing cognitive growth and thus a child’s educational prospects, with major long-term impact on a country’s economy.

The WHO estimates that malaria killed an estimated 409 000 people annually across the globe in 2018 and 2019, (95% of deaths in Africa),

Barnes said that mosquitoes from malaria endemic areas sometimes travelled with people and/or luggage in buses and taxis, spreading the disease to non-endemic areas.

“It happens once in a purple moon, maybe a dozen a year and it’s just bad luck,” she said.

Mosquitoes in non-endemic areas did not carry malaria, she emphasised, while confirming that there had been a few cases in Gauteng in recent years. The only other means of malaria transmission were blood transfusion and congenital transmission, both, “incredibly rare.”

Experts said too many South Africans visiting the Mozambican coastline don’t bother to take prophylactics.

Barnes explained that malaria ‘elimination’ was defined as well-documented zero local transmission for three years running while ‘eradication’ meant ridding the entire world of a disease.

Sherwin Charles, CEO of Goodbye Malaria, the largest NGO of its kind in SA, told Medbrief Africa that he was ‘very happy with the government’s progress and recommitment to the eradication of malaria.”

Professor Lucille Blumberg, Director of the National Institute for Communicable Diseases, (NICD), said a major limitation for malaria was the supply of vaccines for high-risk countries, hence the urgent need for trial and manufacture in African countries. However, South Africa had a low malaria transmission risk, and a vaccine was not indicated.

Covid/malaria misdiagnosis warning

Both Charles and Blumberg said that the ostensible end of the Covid pandemic meant dramatically reduced chances of doctors misdiagnosing malaria as Covid (or vice versa), due to their remarkably similar presenting symptoms, avoiding potentially lethal consequences. The treatments for the two diseases differ markedly.

The latest developments come less than a fortnight before World Malaria Day (April 25th), which recognises global efforts to control malaria. Globally, 3.3 billion people in 106 countries are at risk of the disease.