This month, Ghana and Nigeria became the first two countries to approve the use of R21, a vaccine that may have game-changing effectiveness in protecting people from malaria. The emergence of effective vaccines promises a new golden age of success in the fight against malaria, just as such efforts had appeared to slow and even reverse. However, such promise must be neither squandered nor overplayed. A deficiency of timely, policy-relevant evidence hampered decision-making about the world’s first malaria vaccine—RTS,S—and cheap and highly-effective technologies, such as insecticide-treated bed nets, have still not reached full coverage. Health officials in malaria endemic countries and donor organisations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and Gavi, the Vaccines Alliance, (Gavi), must make difficult decisions regarding how best to invest limited resources in this new age of malaria control and, hopefully, elimination.
In this blog, we call for integrated, national priority setting mechanisms to be in the driving seat in malaria decision-making; supported by scenario-based, context-sensitive guidance from the World Health Organization (WHO) or regional bodies, locally customisable health technology assessment (HTA) models, and well-coordinated donors; and provided with pragmatic evidence that is focused on meeting these decision maker’s needs. Through this, we can ensure the world realises the full potential of malaria vaccination.
Tame the inner magpie, with evidence
Like the magpie, we all like shiny, new things. RTS,S understandably caused much excitement, despite being only moderately effective, with between 30-40 percent reduction in malaria cases (depending on specific circumstances). Early evidence suggests that R21 is significantly more effective, perhaps preventing as much as 80 percent of malaria cases in those vaccinated—the first malaria vaccine to break WHO’s target of 75 percent efficacy. While this first trial is relatively small (n=450), findings from a much larger trial (n=4800) are due soon.
There are, however, a range of existing cost-effective tools in the box for malaria control, and alternative healthcare investments that have not been fully rolled out. It is vital that vaccines build on these strong foundations and do not undermine them. In malaria, this means vector control (including using appropriate bed nets), early diagnosis, treatment using an artemisinin combination therapy (ACT), and intermitted preventative treatment. Resources spent on malaria vaccines are likely to take away from resources spent on these foundational interventions, and this opportunity cost must be carefully considered. For decision-makers to make the right calls on whether or how much to spend on RTS,S now, expand conventional measures like bed nets, or hold out for R21 roll-out, the right evidence is needed at the right time, supported by rigorous national priority setting systems, with regional and global support...